How Did the 2021 E&M Guidelines Impact your Coding?

By Frank Cohen

Validating the shift to higher office visit levels and the impact of the 2021 E&M guidelines.

Between 2019 and the end of 2021, a lot changed. Not only did the COVID-19 pandemic impact the way in which physicians and hospitals saw patients, but the introduction of the new 2021 Evaluation and Management (E&M) guidelines was an additional disruption in the middle of the existing disruption. From my perspective, the result was a great deal of uncertainty in trying to determine what was “normal” and what was aberrant when it came to E&M coding, particularly for office visits.

The primary changes from 2019 through the end of 2020 were due to the pandemic. Medical practices were, more or less, thrust into the world of telehealth and remote visits. And while those models were not necessarily new, they were certainly underutilized. For just the first few months of 2020, after the declaration of the Public Health Emergency (PHE), we saw several changes in the telehealth guidelines and rules, adding to the confusion that this shift had already caused.

Last year, we produced a report that summarized our analysis of the changes in office visits between 2019 and 2020. In general, we saw a significant increase in the utilization of the two lowest levels of new and established office visits; specifically, we saw an 84.9 percent and 63.1 percent increase in the use of new office visits codes 99201 and 99202, respectively. And for established office visits, there was a significant increase in the use of 99211 and 99212 codes (54.9 and 28.0 percent, respectively). This data was based on utilization reported by our clients, totaling nearly 10 million new office visits and over 47 million established office visits. Reporting was done by over 60 unique specialties.

Between 2020 and the end of 2021, the landscape looked completely different. First of all, code 99201 was eliminated, which would explain a reduction in the use of that code in 2021 to almost zero. But we also saw a significant reduction in the use of 99202 as well as code 99211 (down 42.5 and 10.0 percent, respectively). For each category (new office and established office visits), because they create a closed loop, changes in one code naturally impact the distribution of other codes within the same category. So, where did those changes occur? One might assume that since code 99201 was eliminated, we would have seen a big uptick in the use of 99202, which we have already seen was not the case. Rather, we saw a significant increase in the reporting of 99204 (44.0 percent) and 99205 (16.7 percent) for new office visits, and 99215 (up 28.5 percent) for established office visits.

The reasons for these changes are bit unclear. Certainly, we can attribute some of the shift to the new 2021 guidelines, which were a significant departure from the old and well-established 1995 and 1997 coding guidelines. But we were also in the midst of the COVID-19 pandemic, and not being able to control for either of these changes, it’s anyone’s guess as to why these dramatic shifts within each category really occurred.

With respect to raw numbers, we saw an 18-percent decrease in office visits of all kinds between 2019 and 2020. And this included telehealth visits that were coded using office visit codes. Of the two categories, established office visits were impacted the most, with a reduction of 19.6 percent, versus new office visits that saw a reduction of 9.4 percent. 

2021 saw an almost symmetrical rebound of those numbers to an increase of 21.2 percent over 2020, and only about a half of a percent change from 2019. In other words, despite the pandemic, it would appear that visit volume, at least for our physicians, had returned to pre-pandemic levels. The increases for each of the categories were about equal as well, with new office visits rebounding by 20.9 percent and established office visits rebounding by 21.3 percent.

Table 1: Office visit utilization comparisons, 2019-2021

Illustration 1: Office visit utilization for 2021

That’s utilization. Of greater import, at least to our clients, has been whether those changes (particularly the increases in the higher-level codes) are justified. In essence, they have been concerned that reporting increases in the 99205, 99205, and 99215 codes would increase their risk of an audit – and, if audited, the likelihood they would be at risk. To determine the impact of these changes, I reviewed the results of over 100,000 audits of new and established office visit codes performed by auditors within our clients’ organizations. 

With the exception for procedure code 99212, changes for those audits of all other new and established office visits codes were mostly within an expected margin of error. In essence, between 2019 and 2020, the pass rate for office visit codes (except 99212) was statistically significantly the same, for both expected and positive results. This would indicate a consistency in both coding and auditing across our client base. For code 99212, there was a larger increase in both the percentage of audits that passed (15.6 percent) as well as a reduction for those that were deemed as under-coded (30.3 percent). Truth be told, I can’t explain the ”why” behind this change, nor, because of the code level itself, can I venture a guess at the impact this might have. The latter is because I have never seen an outside auditor focus on the low-level E&M codes. But one thing to keep in mind is that, between 2019 and 2020, we did see a very significant increase in the volume of use for 99212 (28.0 percent).

The important change, in my opinion, had to do with the three codes mentioned before, 99204, 99205, and 99215, since these are most often the target of external audits on monitoring of office visits. Remember, we did see a pretty hefty increase in the overall use of those codes (based on raw volume), and the concern is whether those increases were justified. Well, the results are in, and they are for the most part unremarkable. Between 2020 and the end of 2021, which accounts for a full year on the new E&M guidelines, we saw an increase of the number of audits on code 99204 that passed of 12.7 percent and an increase in the number of audits for code 99205 that passed of 3.5 percent. For code 99215, between 2020 and 2021, the pass rate was almost identical, varying by only 0.12 percent.

Table 2: Audit results for all office visits showing pass rates

Illustration 2: Office visit documentation reviews for 2021 (pass rate)

In general, there was an insignificant change over the three years in the overall pass rate of audits for all office visits. For 2019, it was 85.2 percent. For 2020, it was 84.9 percent, and for 2021, it was 86.8 percent. 

My conclusion is that while we did see a fairly significant shift in volume from lower to higher E&M code levels between 2020 and 2021, those changes were, for the most part, justified. As such, while the risk of an audit may have increased, the risk of damages has remained the same. In essence, auditor findings of error rates should remain consistent across all three years. For medical practices, that is good news. Increases in level means an increase in paid amounts, and for most, an increase in profits.

And the fact that the pass rates remained consistent means that they just might be able to keep more of the money they earned.

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