Skip to main content

How the 2021 Medicare Rule Changes Will Affect Your Hospital Billing Guidelines

February 1, 2021
The Centers for Medicare & Medicaid Services (CMS) aims to reduce the burden placed on physicians required to adhere to the current coding system and reward them accordingly for their time spent managing and evaluating patients.

In the final rule, the CMS makes several changes to streamline reporting processes. This rule affects office and patient evaluation and management (E/M) services, particularly to align E/M coding with the AMA CPT Editorial Panel for office/outpatient E/M visits and to indicate their growing support for telehealth services by making some expansions from the COVID-19 PHE permanent. This rule went into effect on January 1st, 2021. 

Similarly, Coronis Health is committed to ensuring that you can spend as much time as possible with your patients while staying on top of hospital billing guidelines by dedicating our services to simplifying hospital billing services. We are a global company with a personal, high-touch medical billing service. Our 100+ years of combined experience has allowed us to bring together the most innovative and thought-advancing leaders in hospital medical billing and revenue cycle management, progressing this industry into the modern, technological age. We make sure you can address any operational or administrative workflow adjustments, so you stay in front of any changes while focusing on patient care.

Changes that Will Affect Hospital Medical Billing

These changes are a response to the issues encountered with the healthcare documentation system. Physicians have always expressed concern about how accomplishing the healthcare documentation process takes so much of their time away from caring for patients. Furthermore, the final rule changes conform to the “Patients Over Paperwork” initiative of CMS to cut the “red tape” by removing regulatory obstacles. By reducing administrative burdens, medical billing in hospitals can be more efficient and patient-centric. The new CPT changes will reduce the time needed for physicians to complete the documentation process of visits, allowing them to spend less time on hospital medical billing and spending more time on patient care.

E/M Requirements

Previously, E/M “time” only covered how long physicians spent on face-to-face activities with patients. But effective Jan. 1, it now includes non-face-to-face work on the date of service, and providers must document the visit on either time or Medical Decision Making (MDM). Activities that may count as non-face-to-face include:

  • Reviewing documents (e.g., test results, medical history) in preparation for a patient’s visit
  • Counseling and educating the patient, family, or caregiver
  • Care coordination
  • Ordering medications, tests, or procedures
  • Referring and communicating with other health care professionals 
  • Documenting clinical information 
  • Independently interpreting results and communicating results to the patient, family, or caregiver

If MDM is used to determine the E/M code for the outpatient visit, the physician will weigh certain factors depending on the site of service. For an office setting, factors in MDM include:

  • Number and complexity of problems addressed
  • Amount and/or complexity of the data reviewed and analyzed
  • Risk of complications and/or morbidity of patient management

For an evaluation made in an inpatient setting, factors include:

  • Number of diagnoses or management options
  • Amount and/or complexity of data to be reviewed
  • Risk of complications and/or morbidity

If time is used to determine the E/M code, new time values will be applied. The definition of time has changed from “typical face-to-face time” to “total time spent on the day of the encounter.” Providers will now focus on increments of time spent on the day of the encounter with the patient. For example, for new patient codes, times begin at 15–29 minutes for CPT code 99202 and then advance in 15-minute increments with 99205 assigned 60–74 minutes. For existing patients, the time element was removed from CPT code 99211. For CPT code 99212, the time for the encounter will be 10–19 minutes. Ten-minute increments are used for codes 99213 and 99214. CPT code 99215 has a 15-minute time frame and is utilized for exams 40–54 minutes in duration.

Current Procedural Terminology (CPT) Changes

Other key changes to coding include the following:

  • Eliminating history and physical exam as elements for code selection
  • Allowing physicians to choose whether their documentation is based on MDM or total time.
  • Promoting payer consistency with more detail added to CPT code descriptors and guidelines
  • Retaining five levels of coding for established patients
  • Reducing the number of levels to four for office/outpatient E/M visits for new patients
  • Revising the code definitions
  • Revising the times and MDM process for all codes

Telehealth for Medicare Updates

Telehealth has proven to become a valuable healthcare asset during the PHE. Recognizing its value in improving healthcare accessibility, the Final Rule has created an expanded list of covered telehealth services specific to the PHE. Also, certain temporary codes added during the onset of PHE are now permanent.

Telehealth services added to the Medicare telehealth list include:

  • GPC1X – Visit Complexity Associated with Certain Office/Outpatient E/Ms, 
  • 99417 – Prolonged Services
  • 99334, 99335 – Domiciliary, Rest Home, or Custodial Care Services
  • 99347, 99248 – Home Visits

You may view all updates on policy changes here.

How Our Medical Billing Services Can Help Your Hospital Stay Compliant

At Coronis Health, we understand the importance of staying abreast with new hospital billing guidelines, and we are here to help you smoothly navigate through the ever-changing field of hospital billing services. Staying informed is essential in this industry. Therefore, our practice managers remain constantly vigilant and compliant with these billing and documentation regulations and compliance requirements. Your most vital financial asset is your billed services and accounts receivable, so we make sure it is well-organized, tightly managed, and safeguarded by a professional medical billing services team. As trusted advisors and technological innovators, we can input coding instantly and execute collections fast and efficiently.

Schedule an Assessment with Coronis Health 

Changes in regulations for billing in hospitals can be challenging, especially for smaller private practice physicians. You will need a partner who can help you adapt by providing proper education and medical billing & coding solutions, improving your productivity, and achieving financial success. To learn more, schedule a consultation with Coronis Health today or request a free financial checkup.

Get the Latest RCM News Delivered

Receive practical tips on medical billing and breaking news on RCM in your inbox.

Get in Touch