Billing Insurance is Easier Than Ever for Functional Practitioners in 2021

Beginning January 1, 2021, there are changes coming to the Evaluation and Management (E/M) office visit coding and documentation requirements. The billing and coding process is moving from one built around paperwork to one built around the patient and the physician! 🎉 Here’s a guide to these new changes and how they affect you as a functional medicine practitioner. 

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Please note: This is not legal or medical advice. 

Contents:

1. What are these changes and why are they important? 
2. You now need only to document a clinically-relevant history and exam.
3. You can bill by time or by medical decision making.
4. You can bill for both face-to-face time and admin time.
5. You need only to meet two of the three elements of MDM to qualify for a specific code.
6. What does this mean for functional and integrative medicine practitioners? 
7. Where can I find more information? 
8. Sources
   

1. What are these changes and why are they important?

The E/M office visit coding and documentation requirements are changing for the first time since 1997. These changes are designed to “make E/M office visit coding and documentation simpler and more flexible, freeing physicians and care teams from clinically irrelevant administrative burdens that led to time-wasting note bloat and box checking” (1). These changes may be enough to cause some providers, who previously decided not to participate in the payer system due to the administrative burden, to revisit that decision and begin billing insurance. 

There are two major changes coming: the amount and type of documentation needed to qualify for specific codes and how these visits are coded - by time OR by medical decision making. 

2. You now need only to document a clinically-relevant history and exam.

Previous regulations required office visit documentation to include certain elements, like history of present illness and review of systems, to be included in order to qualify for higher-level codes. This information was not always clinically-relevant and took significant time to complete.

In contrast, code descriptors now state that providers must perform and document only a clinically-relevant history and exam. You need only to add information that is clinically relevant to you and the patient you are treating, as long as there are some details given beyond “the patient is doing well.” There is no rule on what it has to look like!

3. You can bill by time or by medical decision making.

Visits will be coded in one of two ways - by time OR by medical decision making. You can choose your coding method on a patient-by-patient basis, depending on which is better for that situation. If you spend a lot of time with your patient, it may be best to bill by time. If you are managing a lot of chronic illnesses with a patient, it may be best to bill by medical decision making. Keep reading to learn more about these new coding methods.

4. You can bill for both face-to-face time and admin time.

Previously, you were only allowed to document time that was spent on counseling and coordination of care for a patient. Now, the total physician/qualified health care professional time, both face-to-face and not face-to-face, spent on a patient on the date of the patient’s visit can be documented and used for insurance coding and billing. Examples of activities for which you can bill include, but are not limited to:

1. Preparing to see the patient
2. Performing an exam
3. Counseling the patient/patient’s family
4. Ordering medications or procedures
5. Referring and communicating with other healthcare professionals
6. Interpreting results
7. Documenting clinical information into the electronic health record (EHR) 

5. You need only to meet two of the three elements of MDM to qualify for a specific code.

Coding by medical decision making (MDM) will still use the same elements previously involved in MDM (number and complexity of problems addressed, amount and/or complexity of data to be reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management). However, how each of these elements qualifies for code selection has been redefined. 

To qualify for a specific code, you need only to meet two of the three elements of MDM, a major change from previous regulations. Codes are determined based on the restructured MDM chart, which now includes social determinants of health. Social determinants of health are things happening in the patient’s life, such as housing and economic circumstances, psychosocial circumstances, and social environment, that have a significant effect on their chronic illness. These can now be used to meet the complications risk element of MDM, as long as they are appropriately documented and have an impact on the patient’s chronic illness or treatment plan. 

6. What does this mean for functional and integrative medicine practitioners? 

These changes are incredible news for functional and integrative medicine practitioners! It is now faster and easier for you to bill insurance. 

There is no longer a need to “game” the system in order to bill insurance. Telephone contacts, virtual visits, and even remote patient monitoring, all important pieces of many functional medicine practices, are now payable. In addition, the administrative burden required to bill insurance has been reduced. 

If you are operating a cash-pay practice, now is a great time to consider moving towards billing insurance. This switch could help more patients get coverage for and access to the care you provide.

7. Where can I find more information? 

The best place to find information about these changes is the AMA’s website. This will have the most up-to-date information about all changes to CPT® codes and regulations. 

In addition, on December 22, Laurie Hofmann and Tom Blue from Virtual Practices hosted a webinar with Sonda Kunzi, CEO of Coding Advantage, to discuss these upcoming changes and their importance to functional and integrative medicine practitioners. You can watch the replay of that webinar and view the associated resources to learn more about how these changes will affect you. Be on the lookout for more webinars from Virtual Practices on this topic in early 2021! 

8. Sources

1. American Medical Association. (2020). AMA releases 2021 CPT code set [Press release]. 1 September. Available at: https://www.ama-assn.org/press-center/press-releases/ama-releases-2021-cpt-code-set.