In response to receiving even more questions after last week’s eblast (and becoming more confused myself), I thought it would be best to reach out to my dear friend and colleague Dr. Jeffrey Lehrman (Lehrman Consulting, LLC).
On December 30th I asked. . .
“I was wondering if you could provide some additional insight regarding how private payers will handle the upcoming E/M coding changes (documentation requirements and potential adjustments to levels of visits and reimbursement). I was under the impression that private payers would be a “wait and see” after January 1st as most often they do not follow suit with CMS changes.
To this Dr. Lehrman graciously responded. . .
“The 2021 E/M changes apply for all patients, regardless of insurance. The reason for this is the changes were made by CPT. These changes were not made by Medicare or any payer. They were made by CPT. The new office / outpatient E/M guidelines should be followed when submitting claims to any payer that accepts CPT codes…which is all of them! (with the only exception being possibly a workman’s comp plan).
I have seen it incorrectly reported that this is a Medicare-only thing or Medicare and Medicare Advantage-only. That is wrong. The changes are in the 2021 CPT book. No payer can choose to accept or not accept CPT guidance. If they accept CPT codes, they accept what’s in the book.
I have also seen it incorrectly reported that you should not use the new E/M guidelines for a third-party payer until that third party payer “announces” that they are accepting the new guidelines. This is wrong, but I think I know where this confusion stems from. I suspect this comes from the fact that CMS announced they were “accepting” the 2021 E/M guidelines changes. Here is why that was necessary and does not apply to any other third-party payer: Prior to 2021, the CPT E/M guidelines were very vague and only gave us words like “expanded problem focused” and “detailed” with no quantification of what actually needed to be done. CMS provided clarification with the 1995 and 1997 E/M Documentation guidelines. CMS was the only payer that provided these clarifying guidelines. Now that CPT has cleaned up this office / outpatient E/M section and provided all the specificity needed, CMS needed to announce they were accepting these changes in place of their 1995 and 1997 guidelines for CPT 99201 – 99215.
Saying you have to wait for a third party to “announce” they are accepting the new E/M guidelines would be no different than saying, “When submitting CPT 11721 to a third-party payer, don’t assume that payer considers 11721 to be debridement of 6 or more nails until they announce they agree with what is in the CPT book for that code.”
All of the above can be summed up with one sentence:
The changes were not made by any payer; they are in the 2021 CPT book and any third-party payer that accepts CPT codes has to accept what is in the CPT book.
I know some have received incorrect information on this, which stinks. If it makes them feel better, here is UHC (the largest non-Medicare payer in the country) referencing the 2021 CPT changes: https://www.uhcprovider.com/en/resource-library/news/2020-network-bulletin-featured-articles/1220-updated-e-m-reimbursement-policy.html
Also, if you google, “blue cross blue shield 2021 evaluation and management”…I only looked at the first 20 hits, but every one of them is different BCBS state plans from around the country referencing the 2021 changes.
Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC
Lehrman Consulting, LLC
Certified Professional Coder
Diplomate, American Board of Foot and Ankle Surgery
Fellow, American Academy of Podiatric Practice Management