2021 E&M Coding Effect on Compensation

[swaggy1090]

So I know the E&M codes are undergoing a major overhaul in 2021, focusing more on MDM rather than hitting a certain number of exam sites etc. What do you think the effect on dermatology will be? I have heard many say that they are concerned it will lower the billing level for full body skin exams, as many of these do not end in a procedure or prescription.

---

Members don't see this ad.

 

[dermie1985]

So I know the E&M codes are undergoing a major overhaul in 2021, focusing more on MDM rather than hitting a certain number of exam sites etc. What do you think the effect on dermatology will be? I have heard many say that they are concerned it will lower the billing level for full body skin exams, as many of these do not end in a procedure or prescription.

Not sure what to expect to be honest. Yes, I think routine skin checks without biopsies may be billed at a lower level in the new system. Most of the disproportionate salary levels in dermatology compared to other specialties are more related to (1) the sheer number of patients we see, and (2) reimbursement for procedures, including small procedures (e.g. cryotherapy, shave biopsies, etc.), rather the E&M codes. For instance, say you do a skin check, freeze 15 AKs, and biopsy 2 spots. I think a level 4 return is about 1.5 wRVUs, and freezing >15 AKs is ~1.8 wRVUs, 2 shave biopsies is about ~1 wRVU - that's ~2.8 wRVUs for procedures and ~1.5 wRVUs for E&M, just from 1 patient. But, yes, it might have an impact.

 

[Slack3r]

If you’re billing mostly level 3 visit (which most derms probably should be for the majority of visits) it’s actually a slight increase in $$ per visit.

They backed off the 50% cut to modifier 25, but I suspect that’s only for now.

 

[dermie1985]

If you’re billing mostly level 3 visit (which most derms probably should be for the majority of visits) it’s actually a slight increase in $$ per visit.

They backed off the 50% cut to modifier 25, but I suspect that’s only for now.

I'd disagree and say you should be billing mostly level 4 return visits. All full body skin checks should be level 4. And any follow-ups where you assess any new problem and prescribe medications, and/or re-assess old problem with any significant level of thinking (e.g. lab monitoring, new medication, dose adjustment, etc.). Return Level 3 for me is an acne follow-up where I just refill meds.

 

[Slack3r]

How are you getting appropriate complexity on your run of the mill return FBSE patient to bill 99214?

 

[dermie1985]

How are you getting appropriate complexity on your run of the mill return FBSE patient to bill 99214?

You only need 2/3 elements for a return visit to be detailed to bill a level 4. Just need to document appropriate level of history to get to detailed history (it's easy), full body skin examination (detailed depending on whether you use 1995/1997 rules). Medical decision making doesn't even really matter.

 

[Slack3r]

My understanding, per our coders, is MDM is the main component that matters. Still not sure how you get to “moderate” in MDM with a FBSE.

 

[dermie1985]

My understanding, per our coders, is MDM is the main component that matters. Still not sure how you get to “moderate” in MDM with a FBSE.

In new rules, yes (MDM is the only thing).
In old rules, for new patients, you need 3/3 elements (History, Exam, MDM) to be detailed to bill a Level 3 New (Return Level 4 equivalent). This is hard to get to for new patients.
In old rules, for return patients, you need 2/3 elements to be detailed to bill a Level 4. Doesn't matter which 2-combination of History / Physical / MDM, the rules are vague on this. In other words, if you have a detailed history and physical, you don't need a moderate level of MDM to bill a Level 4 visit.
Every biller / coder will say something different, because these rules are not actually clearly defined and there's a lot of room for interpretation.

 

[MOHS_01]

How are you getting appropriate complexity on your run of the mill return FBSE patient to bill 99214?

They're not -- just because the EHR coding advisor says "yep, checked enough boxes", you may have met the flowchart requirements -- but these are inadequate to stand on their own, there still is a medical necessity criteria that must similarly be satisfied. Upon audit or review, recoupment is indeed likely. The CMS tracked national rate of 99214 is 16%, by the way....

 

[smartparts]

Yeah I've definitely heard from several people the same thing MOHS said, getting a full ROS or doing unnecessary exam portions is probably not a good idea if you get audited. To me it seems like things won't change all that much, but I might be wrong. Acne follow ups will probably stay level 3 (low # of dx/chronic stable problem + moderate risk for rx meds) but if they are flaring you could technically get to level 4. Skin check follow ups might be a little tougher to get to level 4 on their own, unless you address another problem with an rx medication (rosacea, asteatosis, etc), discuss with dermpath/mohs surgeon, review the slide yourself, or order a blood test. I've heard that a biopsy of something you think is a skin cancer fits the "new problem uncertain prognosis" for moderately complex problem, is that correct?

 

[OraclePL]

In new rules, yes (MDM is the only thing).
In old rules, for new patients, you need 3/3 elements (History, Exam, MDM) to be detailed to bill a Level 3 New (Return Level 4 equivalent). This is hard to get to for new patients.
In old rules, for return patients, you need 2/3 elements to be detailed to bill a Level 4. Doesn't matter which 2-combination of History / Physical / MDM, the rules are vague on this. In other words, if you have a detailed history and physical, you don't need a moderate level of MDM to bill a Level 4 visit.
Every biller / coder will say something different, because these rules are not actually clearly defined and there's a lot of room for interpretation.

The problem is your ROS. With no history of skin cancer, is it appropriate to add a second ROS point after skin? I don't know the answer, I've asked many people and everyone says something different. But without the 2 ROS points your history doesn't meet level 4 criteria, so it depends on your exam and MDM.