New 2021 E/M guidelines: What Psychiatrists and Other Qualified Behavioral Health Professionals Need to Know

By Lisa A. Eramo, MA

Behavioral health medical providers are in the business of helping others, which is why they sometimes forget to help themselves. We’re talking about helping their own practices survive and thrive financially. What’s the most effective way to do this? Report the right Current Procedural Terminology (CPT) codes. Far too often, psychiatrists and other qualified behavioral health professionals underbill because they aren’t aware of new coding guidelines, or they don’t understand how to apply existing ones. The result? They end up leaving money on the table.

Equally as worse are scenarios where psychiatrists bill for services that payers deny. Or they fall into a pattern of billing the same codes repeatedly without realizing they’re putting themselves at compliance risk of becoming an outlier and potential subject of a more comprehensive payer audit.

For example, consider the new evaluation and management (E/M) coding guidelines that took effect January 1, 2021. In a nutshell, these new guidelines state that the history and physical exam will not determine the appropriate E/M code level for E/M codes 99202 through 99215. Instead, these codes will be assigned based on time or medical decision-making (MDM)—the most financially advantageous option can be chosen.  Mental health clinicians must understand these changes not only so they can ensure revenue integrity (i.e., the idea that they are paid accurately for the services they provide) but also so they don’t put themselves at risk for denials, audits, and recoupments.

Some important points to note: These changes do not apply to other CPT or HCPCS codes reported in behavioral health. In addition, these changes only pertain to Medicare, though many commercial payers have adopted them as well. Best advice? Check with your payer before billing services.

Non-face-to-face time counts toward the E/M level

Perhaps the most notable change in E/M guidelines is that non-face-to-face time can now be included if it occurs on the same day as the patient’s appointment.

Here’s a list of the types of tasks that can now be counted towards establishing the correct procedure code when performed on the date of the patient visit:

• Care coordination (when not separately reportable)
• Counseling and educating the patient, family, and/or caregiver
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (when not separately reportable) and communicating results to the patient, family, and/or caregiver
• Obtaining and/or reviewing separately obtained history
• Ordering medications, tests, or procedures
• Performing a medically appropriate exam and/or evaluation
• Preparing to see the patient (e.g., reviewing tests)
• Referring and communicating with other healthcare professionals (when not separately reportable)

Consider this example: A psychiatrist spends 30 minutes reviewing a patient’s discharge summary at 10am and sees the patient for a 30-minute appointment later that day. If the psychiatrist forgets to bill for the time spent reviewing the discharge summary, the service would be a level 99203 (national average Medicare payment of $113.75) instead of a level 99205 ($224.36).

However, as before, when selecting an E/M code based on time, associated time requirements must be met, which have changed in 2021 as follows:

Billing based on medical decision-making may be more advantageous

Note that in some cases, it might make more financial sense to bill an E/M code based on MDM rather than time. That’s because the MDM table of risk has also been revised to take into account factors such as a patient’s social determinants of health and the need to interview an independent historian.

The American Medical Association defines an independent historian as follows: ‘An individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.’

Consider this example: An established patient with early onset dementia presents for 30-minute appointment; however, the mental health provider must also speak separately with the patient’s daughter to obtain important medical information. When selecting an E/M level based on time, this would map to 99212 ($56.88). When billing based on MDM, it would map to 99213 ($92.47).

Here’s another example of how the new MDM table can make it easier to capture revenue: Let’s say a patient presents with stable diabetes mellitus but has recently become homeless due to job loss during the pandemic. By documenting the recent housing insecurity and how that could affect the patient’s ability to manage their diabetes, a 99214 code ($131.20) vs. a 99213 code ($92.47) can be billed.

New prolonged service codes capture additional time spent with patients

Another important change is that qualified health professionals can report two new add-on codes when they spend additional time with or without patient contact. This is particularly helpful for treating complex patients requiring intensive care coordination and follow up.

Report code 99417 for prolonged office or outpatient E/M services once every 15 minutes in addition to 99205 or 99215. For Medicare, report G2212 once every 15 minutes in addition to 99205 or 99215; however, note that the time thresholds are not the same as those for 99417. Here is how both of these codes work:

Summary and Good News

Understanding these new E/M guidelines can help psychiatrists and other qualified behavioral health professionals maintain a financially thriving psychiatric practice so they can focus on what they do best: Provide high-quality mental health care.

To learn more about 2021 E/M changes for psychiatry, please review our new coding course CodeRight, which incorporates and highlights the 2021 changes.

Remember that the sooner you invest the time – and a little bit of money – the sooner you will start to benefit from proper code use while minimizing risk of inaccurate coding.