Hi, it's Dr. Weitz. Thank you so much for joining me for this episode of the private medical practice Academy. Happy new year. I'm sure like me, you're hoping that 2021 is going to be so much better a year. And I'm sure by now you've heard that ENM coding has changed as of January 1st. And I'm also willing to make you a bet that you find the entire thing confusing.

Honestly, the whole ENM coding system has always been a source of confusion. And in case you don't know the history of how it even came about and why it's so confusing. Let me give you an overview before 1992, the CPT code book didn't even have time as a factor in M codes only had descriptors such as brief, limited, and extended. As you can imagine,

this was a huge problem. Physicians were left to interpret what level code to report, and because there really weren't any details or definitions in the book, they struggled. And then in turn, because of the lack of consistency, the insurance companies couldn't assess the clinical documentation and the reported ENM levels objectively. So then in 1992, the AMA included time as one of the criteria for choosing the correct ENM level of service.

The times that were listed in the CPT code book were considered the quote unquote average time a physician spends caring for a patient in quote. So while maybe this was a step in the right direction, it really didn't take all the subjectivity away. And then in 1995 came the bullet system that we all know and hate in order to code and get paid appropriately.

We became so focused on how many bullets we could hit, and we all know how burdensome charting has become. Now, let's be honest. All of this was not done for the good of the patient for providing better patient care or to improve outcomes. The real reason was to control reimbursement fast forward to 2021. Why is the ENM coding changing? Supposedly it's designed to make charting less onerous,

but if you actually read about it, it's because CMS was putting pressure on the AMA the original plan was to collapse office visits for levels two to five into a single payment. Yes. You heard me right? The same amount of money for a nine nine two Oh two as a nine nine two Oh five or a nine nine two one two and nine nine two one five.

Needless to say that was not going to fly after a ton of pushback. We now have the new 2021 coding changes. And in case you think that this time it had anything to do with making physician lives easier, think again, it's still all about reimbursement. Now let's talk about what these changes mean to you. There are multiple changes here, but I'm going to tell you the major ones that you really need to pay attention to.

First of all, they got rid of nine, nine, two Oh one, which is a level one new patient visit. Honestly, I doubt that this affects most physicians, because I can't really think of any instance where anybody actually bills for this code, which is probably why they got rid of it. They added an additional 15 minute prolonged service code that you can tack on two nine,

nine, two Oh five and nine nine two one five. But the really big deal here now drop the mic is how you actually code ENM services. To start with the new guidelines, have eliminated the history and physical elements for code selection. Okay? So while this isn't going to count in any way, shape or form towards your coding, you still need to document the history and the physical exam.

Honestly, I think they took this out because duh, of course, you're going to take a history. And of course, you're going to do a physical exam when appropriate and you're going to document it. Why? Because how else will you or anyone else know or remember what happened at that visit? When that patient comes back in the future, remember you're documenting because you want to take the best care of that patient.

So yeah, you no longer need to click irrelevant bullets, but you're going to want to have enough meaningful content in this note to actually help you and your patient. And needless to say, you also need to document for medical, legal reasons. So of course, now you're thinking to yourself, they took it out. They didn't really take it out.

I still have to do it anyway. So it's not really going to save me any time, right? Not to worry though, you are still going to get coding credit because both the patient history and relevant physical exam contribute to both the time and medical decision making aspects, which are actually the new criteria for coding. So now let's actually talk about those new criteria.

You're going to have to choose between total time or medical decision-making as the basis for your ENM level documentation. Since you're going to have to choose between either time or medical, decision-making, let's talk about the criteria for each of them. Let's start by billing for time before the new changes, there was an enormous amount of confusion about time and hold total time,

time that's face to face non face to. And how do you figure all of this out? And how does that actually figure into the whole billing by time thing? Right here are some definitions that may help you. Face-to-face time is defined as the time a provider spends directly interacting with the patient and or the patient's family or caregiver, and includes tasks like history,

taking examination and counseling. On the other hand, non-face-to-face time is the time that the provider spends managing the patient outside of the encounter, such as before or after direct patient care. Non-direct time includes discussing the case with other healthcare providers reviewing the medical records, ordering tests, ordering services, prescriptions, and time that is spent directly on patient care. Total time is defined as the overall time on the day of the encounter during which the provider provide services related to patient care.

Even if the times aren't consecutive, the time spent over the course of the day is totaled. And you need to understand that the day starts at 12:01 AM and ends at midnight. The reason this is important is that if you prep your charts the day before you don't actually get to include that time for the purposes of total time, the time calculation includes the providers face-to-face and non face-to-face time.

I also want to point out to you that the total time is your total time. It doesn't include the time that it's normally spent by your clinical staff. Let's say you're a medical assistant or a nurse. It really is the time that you, the provider spent. And just to be crystal clear, if you want to code by time. The only thing that matters now is the total visit time.

Here is the AMA list of activities that can be counted towards the physicians total time first preparing to see the patient, including, for example, reviewing the tests or reviewing your notes from the last visit, obtaining and reviewing separately obtained history. Let's say they saw somebody else. And now you're reviewing those notes, performing a medically appropriate examination and or evaluation counseling,

and educating the patient, their family, or caregiver, ordering medications, tests, or procedures. It also includes referring and communicating with other healthcare professionals. Assuming that you're not reporting this separately, it includes documenting clinical information in the record independently, interpreting results and communicating those results to the patient, their family and caregivers. It also includes care coordination. Now I want to mention just briefly the caveat and that is that you cannot bill for things that you are reporting separately and billing for.

So basically in this total time, if you are billing for something else as a separate report, then obviously you can't double dip. Another thing I want to point out is that CMS also got rid of the 50% rule just as a refresher. The 50% rule stated that the duration of the visit is an ancillary factor and doesn't control the level of service to be billed unless you spent more than 50% of the time face to face for,

for counseling or coordination of care. Now with the new 2021 guidelines, you're no longer applying the greater than 50% rule to counseling and coordination because essentially they're already giving you credit for total time. Next, let's talk about medical decision-making to be honest with you, I have always found this to be probably the most confusing part of coding with these current changes. There have been extensive edits in an attempt to simplify how the components of medical decision-making are actually defined.

The first thing that you need to know is that there will still be three sub-components number and complexity of medical problems is one data that you have to review and analyze. And then risk is the third. They use the previous table of risk as a foundation, but have made a number of changes. So for example, they changed some of the terms they've removed ambiguous terms like mild and ambiguous concepts,

like acute or chronic illness with systematic symptoms. They've also improved the definition of a number of terms. And probably my favorite is that they've redefined the data elements to move away from simply adding up tasks, to focusing on how those tasks affect the management of the patient, which is really the way it should have been all along. For example, like independently,

interpreting a test that was performed by another provider and then discussing it with the patient, or maybe discussing a test interpretation with another physician. You also need to know that CMS is adding a new healthcare, common procedure coding system code hick picks used to recognize additional resource costs that are inherent in treating complex patients. The changes to the ENM CPT codes apply to all traditional Medicare and Medicare advantage plans,

Medicaid and all commercial payers. The ENM hit picks codes apply to Medicare and Medicare advantage and Medicaid only because commercial payers aren't actually required to accept hixpix codes. Obviously you're going to have to decide whether it's better to bill by time or medical decision making for each individual visit. I certainly have spent a great deal of time counseling, chronic pain patients, even when the medical decision making just really wasn't that complex.

But the opposite is also been true where the medical decision making was very complex, but the whole process didn't take that long. That billing by time would have made sense. Okay, so now let's get to the heart of the matter. I know that what you're really wondering is whether these ENM coding changes are going to save you any time, make your life easier,

or generate any more money for you. The obvious answer to this is that only time will tell, but my initial impression is that it's unlikely to save you any significant amount of time. Now I do think it may save you a bunch of clicks and it may allow you to better engage with your patients, but I don't think it's going to be a great time to save it similarly.

I don't think it's actually going to make your life any easier where I do think it's going to make a difference is that I think it's going to help you to code and bill correctly and therefore generate more money. Why do I think that? Because for years, everyone was so scared and confused by the contorted in M coding system that physicians tended to under code for fear of overcoding and getting audited.

This was notoriously a great way to leave money on the table. I think that the new 2021 coding changes will actually help you code more correctly with less fear since the criteria are actually clearer than they've ever been. Be sure to check out the show notes for this episode or the blog on my website, Dr. Sandra weitz.com in order to download a schematic of the new medical decision-making table.

Thanks for joining me, be sure to sign up for my newsletter below, and I'll be sending you tips on how to start your practice best run your practice, grow the practice, and then ultimately be able to leverage your medical practice into multiple other businesses. I hope to see you soon.