Evaluation and Management Code Changes Coming in 2021 for 99202-99215

  

While it is only the second month of 2020, it is never too early to look to 2021, when the revised Evaluation and Management (E/M) office codes go into effect per the Centers for Medicare and Medicaid Services (CMS) CY 2020 Physician Fee Schedule (PFS) Final Rule. CMS first proposed the updated Medicare E/M codes July 2018 in the CY 2019 PFS proposed rule to address the common perception that the E/M codes were outdated and to achieve administrative simplification. What is changing?

  • Deletion of code 99201
  • Revision of codes 99202-99215P
  • Components for code selection
  • E/M level of service for office or other outpatient services can be based on:
    • Medical Decision Making (MDM); or
    • Time: total time spent with the patient on the date of the encounter, including non-face-to-face services
  • Creation of a shorter 15-minute prolonged service code

Over the next few months ANA will take a deeper dive into these changes and will continue to share further guidance from CMS. These code changes are intended for increased simplicity and flexibility.  They eliminate the need for the clinician to redocument information, therefore reducing burden and “note bloat”. ANA encourages clinicians impacted to take the next eleven months to better understand how to use the updated codes.

With code 99201 deleted; the Office or other Outpatient Services: new patient code starts with 99202. The updated code states: Office or other outpatient visit for the evaluation and management of a new patient, which requires medically appropriate history and/or examination and straightforward medical decision making. The components of history and examination are removed from this updated code.

This continues for 99203, 99204, and 99205 but with the increase in MDM to low MDM, moderate MDM, and high MDM respectively. Codes 99211 through 99215 are for established patients following a similar pattern, except that 99211 will still be available in 2021 with an update of the time to spend performing or supervising the services.

The updated modifications to the criteria for MDM remove ambiguous terms and defines previously ambiguous concepts (such as acute or chronic illness with systemic systems). To qualify for a level of MDM, two of three elements for that level of decision making must be met or exceeded. Starting January 1, 2021, the new MDM table looks like:

Number and Complexity of Problems Addressed at the Encounter
Straightforward: self-limited
Low: Stable, uncomplicated, single problem
Moderate: multiple problems or significantly ill
High: very ill
Amount and/or Complexity of Data to be Reviewed and Analyzed Data is divided into three categories: (1) tests, documents, orders, or independent historian(s) – each unique test, order, or document is counted to meet a threshold number; (2) independent interpretation of tests not reported separately; (3) discussion of management or test interpretation with external physician/other Qualified Health Professional/appropriate source (not reported separately)
Risk of Complications and/or Morbidity or Mortality of Patient Management
Includes risks associated with social determinants of health
Straightforward: minimal risk from treatment – including no treatment – or testing. (effectively no risk)
Low: low risk/very low risk of anything bad, minimal consent/discussion Moderate: would typically review with patient/surrogate, obtain consent and monitor, or there are complex social factors in management (ex: prescription drug management, decision regarding minor surgery with identified patient or procedure risk factors, diagnosis or treatment significantly limited by social determinants of health)
High: need to discuss some pretty bad things that could happen for which physician or other qualified health care professional will watch and monitor (ex: drug therapy requiring intensive monitoring for toxicity, decision regarding emergency major surgery, decision regarding hospitalization)

ANA will continue to provide updates and content as clarifications become available. Currently, The American Medical Association has a module to continue in your education on the updated E/M Office Codes and remember that these codes do not go into effect until January 2021.

Congressional and Judicial Actions Addressing Border Conditions

  

By Brooke Trainum and Janet Haebler

As we celebrate America’s birthday and the freedoms we enjoy, recent headlines remind us that others’ have not been as fortunate. The July 4th holiday comes right after a federal judge’s order to US Customs and Border Protection (CBP) addressing concerns in detention facilities holding refugees. On June 28th, a federal judge in Texas ruled that “CBP must permit health experts into detention facilities holding migrant children to ensure they’re ‘safe and sanitary’ and assess the children’s medical needs.” This order is only applicable in the El Paso and Rio Grande Valley regions, due to the subject of the lawsuit. Judge Dolly Gee gave the Trump administration a deadline of July 12th to report what they have done to correct the conditions. This ruling is on the heels of Secretary of Health and Human Services Alex Azar stating in an interview shared by Politico that “the centers run by CBP were not good conditions for kids to be in.”

The situation at the border is complex in nature and for many that can lead to a feeling of helplessness and despair. ANA has repeatedly expressed concerns with the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS) and Congress, most recently via a June 2019 letter sent to DHS. Additionally, Congress recently passed emergency supplemental funding to help alleviate this situation. Given the complexities of this issue there was even disagreement within the political parties on how to address this crisis.

The reports coming from these detention facilities are unfathomable. There are two main government agencies that oversee refugee shelters, with both DHS and HHS each carrying a different mission. The Office of Refugee Resettlement (ORR) within HHS is specifically responsible for unaccompanied minor children; however, it has been the facilities overseen by DHS and CBP that has made the news most recently as having unsafe, unsanitary, and inhumane conditions.

What many do not realize is the unacceptable conditions of border detention facilities is not new. Greater media attention has highlighted the situation. Accommodations erected decades ago were intended for single males, not families. The situation has been exacerbated by a backlog in the immigration court system. Under standard procedures, detention is intended to be for a short duration, not exceeding 72 hours, while claims for asylum are received and processed. Yet, it has been reported that in mid-2019, the average length of detention exceeded one week. In May and June 2019, between 14,000 and 18,000 people were held by CBP each night. And yet another confounding factor is that several of the detention facilities housing refugees are operated by private corporations who have contracts with Immigration and Customs Enforcement (ICE).

While many agree that immigration laws need to be reviewed and modernized, this is an issue where many Americans are split on the solution. Due to this divide, ANA has focused on the immediate issue of a humanitarian crisis affecting the health and well-being of those impacted at the border. As nurses, we have a duty through the Code of Ethics for Nurses to speak out and advocate for the human rights and health care needs of all, particularly the most vulnerable.

ANA works to ensure nurses are equipped to treat their patients’ pain effectively

  

As the largest healthcare provider group in the country, nurses are no strangers to treating pain, including chronic, acute, and emotional pain. Nurses are also subject to their own personal pain, and they are not alone. Today, there are approximately 50 million adults in the US living with chronic pain and over a third of those adults’ pain interferes with their daily activities. ANA is monitoring and advocating along with our nursing partners, around the Department of Health and Human Services Pain Management report due to be finalized later this year, that promises to help providers use evidence based treatments to manage their patients’ pain while considering the nationwide opioid epidemic.

In 2011, the Institute of Medicine recommended that pain and relieving pain should be a national priority. The report goes on to say that pain is a chief driver for visits to physicians and other healthcare providers, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. We have all experienced pain and for many, if not all nurses, we have had to decide how and to what degree to treat that pain.

The Code of Ethics for Nurses with Interpretative Statements (the Code) mandates that nurses have an ethical obligation to treat their patients’ pain without bias. To minimize biases, the nurse must identify the influences and intentionally set them aside. However, the Code does not say how they must treat pain. For many what first comes to mind is treatment that involves opioids. For some diagnoses, opioids are part of the best clinical practices for treatment; for others, it may be a combination of pharmacological, restorative, and alternative therapies. Patient adherence, access, coverage, and social determinants may all affect the best option for the individual.

More recently, there has been a renewed interest in the role of pain with regards to the opioid epidemic. Pain is a separate disease from the addiction and dependence that can come from opioid use, a fact which has been recognized by the Department of Health and Human Services Pain Management Best Practices Inter-Agency task force. Encouraging to nurses, the task force recommends an individualized and multidisciplinary approach to chronic pain that also includes increased insurance coverage for Complex Management Situations. It also calls for safer opioid stewardship through a risk assessment based on the patients’ medical, social, and family history.

Nurses are also positioned to provide care coordination activities for improved patient outcomes to patients and their families suffering from chronic pain conditions and associated co-morbidities. ANA commented on the draft pain management report and will continue to advocate the role of nursing in treating chronic pain to the task force and agency. The task force will meet on May 9th and 10th to vote on final recommendations.

Recognizing pain as not just a symptom, but rather a disease for some patients, may help shape the patient-provider relationship and higher quality outcomes of care. Pain can have devastating personal, financial and social consequences. Reshaping how nurses talk about pain with their patients and taking the time to learn about and advocate for alternative therapies available in the community, can help in the immediate care of a patient and the long-term ability to complete activities of daily living.