Q&A: Preparing hospitals for the 2021 E/M overhaul

Q: How will the expected E/M leveling guidelines changes affect hospital visits in 2021?

A: Under Medicare, E/M codes have a status indicator of B (code not recognized by OPPS when submitted on an outpatient hospital Part B bill type) meaning the coder should report a different code to better describe the visit services. For hospitals billing under the Medicare Physician Fee Schedule, irrespective of the level of care provided, coders should report HCPCS code G0463 (hospital outpatient clinic visit for assessment and management of a patient) for outpatient visits.

However, coders may see different prices associated with E/M visit levels in their chargemaster for services billed to commercial payers and Medicaid. These will all be mapped to G0463 for Medicare and this comports with CMS’ definition of charges found in CMS’ Provider Reimbursement Manual, Part 1, Section 2202.4.

The American Medical Association (AMA) recently published its 2020 CPT® code update that includes six new time-based codes for online digital E/M services. Based on the new CPT guidelines, it seems likely that facilities may establish charges for billing some of these E/M services and would use OPPS status indicators as well AMA guidelines for time-based E/M reporting of these codes.

The question of whether CMS’ E/M guidelines apply to the 2021 E/M updated code set and coding guidance has yet to be addressed by the AMA.  

Editor’s note: This question was answered by Valerie Rinkle, MPA, lead regulatory specialist with HCPro, a Simplify Compliance brand, in Middleton, Massachusetts, and Jugna Shah, MPH, president and founder of Nimitt Consulting in Washington, D.C., during the HCPro webinar, 2020 OPPS Final Rule: Implementing the Latest CMS Policies.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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