2021 Office Visit Code Changes: A Positive Impact for Your Bottom Line

Rose Nierman shows how staying aware of code changes in billing office visits can improve the patient experience and save dental practices time and aggravation.

Code changesby Rose Nierman, Founder & CEO, Nierman Practice Management

I know. I get it. Medical coding may not be the most exciting subject matter, but trust me on this one – it’ll pay to keep reading! It will be worth the time, and the information may even increase your bottom line. Much anticipated and long overdue updates to office visit codes, referred to as evaluation and management (E/M) codes, promise to improve the patient experience and save dental practices time and aggravation when billing medical insurance for office visits.

The documentation requirements for E/M services were established ages ago (one set of guidelines was written in 1995 and another in 1997) and have been in desperate need of revision. Beginning January 1, 2021, changes to the Current Procedural Terminology (CPT®) structure for office E/M services take effect. Thankfully, the documentation guidelines have been totally revamped!

Previous documentation guidelines did little to support patient care. Instead, they served more as a scoring system to justify a level of office visit billing (e.g., level 2, 3, or 4), rather than help providers diagnose, manage, and treat patients. This adherence to E/M documentation guidelines consumed a significant amount of time and did not necessarily reflect the actual work of providers.

How the new guidelines help providers with office visit requirements:

  • Eliminate the exam as key elements for code selection
  • Allow providers to use medical decision making (MDM) or total time spent as the key element for code selection.
  • Modify MDM criteria to move away from simply adding up tasks to focusing on tasks that affect the management of a patient’s condition.

The new CPT guidelines lean more toward time spent caring for patients rather than spending time calculating how many “body systems” or “bullet points” are reviewed or assessed. Dr. Barbara Levy of the CPT editorial board states, “I think the new guidelines will be far more intuitive. For doctors, it’s going to be terrific.”

Coding from the SOAP Report

Dr. Levy explained that the new E/M documentation will be more strongly based on the traditional SOAP – subjective, objective, assessment and plan – in which providers document what the patient was there for (subjective), what was learned from their history and exam (objective), and then what the provider judged to be the problem (assessment), and the strategy (plan) for dealing with it. 

Primary objectives of the CPT office visit revisions

  1. Decrease administrative burden of documentation and coding.
  2. Abate the need for audits on this coding set.
  3. Reduce documentation not needed for patient care in the medical record.

Were any codes deleted?

Yes, CPT code 99201 for a new patient problem focused history & exam is officially deleted from the Current Procedural Terminology (CPT) medical code set as of January 1, 2021 since it was similar to the level 2 code. This deletion is not considered an issue since DSM dentists typically spend more time in consultation than this code reported.

Is the established patient level 1 exam code still valid?

Yes, level 1 code, CPT 99211, for established patients has not been deleted. You can still utilize this code in 2021.

Can the established patient code, 99211, be selected for a patient’s time with my clinical staff?

Yes, you can use 99211 for staff who perform face-to-face encounters. 99211 is for a minimal problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision.

Can dentists now select E/M based on Total Time Spent?

Yes, providers can select an exam level based on their time providing care even when not face-to-face. Additionally, providers will not need to specify that counseling and coordination of care dominated the visit to use time to support the level of care.

See Tables 1 and 2 for new guidelines with time ranges for total time spent.

Code changes
Note: 99211, established patient E/M code, is still available, but its code descriptor does not include a time reference

Since we can now bill based on Total Time Spent, what is included?

There is a long list of activities that can be considered for total time spent! It includes time in activities that require the physician or other qualified health care professional but does not include time in activities typically performed by clinical staff. Here are some examples:

  • Preparing to see the patient (i.e. reviewing test results)
  • Obtaining & reviewing history
  • Performing the exam/evaluation
  • Counseling/educating the patient/family
  • Ordering meds/tests/procedures
  • Communicating with other health care professionals
  • Documenting clinical information in the chart/health record

The SOAP format is much more intuitive than the checking of predetermined bullet points to document care. “That’s the way our brains work,” says Dr. Levy. “We’re getting to the place where we’re documenting what’s important for patient care and for communication with our colleagues.” With these new guidelines, dentists and their teams can now choose the level of E/M code for their visits with confidence from their SOAP reports – as it should be!

We at Nierman Practice Management welcome these changes with open arms and excitement, as the ability for the dental practice to use total time spent as the key factor for selecting the appropriate level of E/M code is very beneficial. This simplifies the selection criteria and now allows for higher levels of office visit codes to be utilized than ever before. For a link to the new E/M guidelines, please send a request to my office at Contactus@dentalwriter.com.

Attorney Jayme R. Matchinski looks at code changes in the provision of oral appliances and regulatory compliance in her article in Dental Sleep Practice:

Code changesRose Nierman’s CrossCoding: Unlocking the Code to Medical Billing in Dentistry course is available in-person, live-stream, or as an online course. Rose and her team have helped thousands of dental practices implement medical billing for DSM, TMD, and oral surgeries. Her company, Nierman Practice Management, created DentalWriter™ software to generate SOAP narrative reports and claims for dentists billing medical insurance in-house or as outsourced billing. Rose and her team have been dedicated to helping dentists and their teams for 32 years. For more information: contactus@dentalwriter.com or 800-879-6468.

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