Why you might choose differently this year

In my last column, I briefly reviewed how Evaluation and Management (E/M) exam coding for 2021 had changed as of Jan. 1 (tinyurl.com/wuyrpo5r ). Remember, history and exam elements (other than the reason for presentation, chief complaint) are no longer a relevant consideration for the level of E/M exam code selection.

In that column, I alluded that it was important to understand that the payments for eye exams are not stagnant; they change slightly every year. This year, it may result in your “choosing differently” than you have in the past. In this column, I will discuss what implications the 2021 Final Rule on the Medicare Physician Fee Schedule (MPFS) reimbursement may have on your choice of code. Remember, if an eye exam can meet an eye (920xx) code and an E/M code under the new guidelines (99202-99215), the provider can choose the higher paying of those two and remain in full compliance with coding guidelines.

Review payment changes

While initially eye code payments were slated to go down, in the Final Rule they are largely neutral or slightly up — as are E/M “new” status exam payments for the most part. The real change is in the payments for “established” status E/M exam payments — up dramatically over the prior year. Historically, codes do not change more than 2% to 4% in a single year.

Included are two Tables: Table 1 shows the year-over-year change, while Table 2 shows the national Medicare payments for 2021. The codes with increased payment of more than 10% in 2021 are in boldface. Also, 99201 is deleted for 2021, which is why it shows a 100% decrease.

Your area’s payment may be slightly higher or lower due to regional differences on things, such as practice costs. Someone practicing ophthalmology who files a claim for a Medicare Part B eye exam in Manhattan, NY, gets a higher payment than someone in Manhattan, KS.

Choose wisely

Common comparable exam levels when I audit records often meet 92014 and 99214; the other common scenario is that an exam might meet both 92012 and 99213. Historically, the eye code has been the clear winner. That changes in 2021, although it’s not the runaway winner as in the recent past. In Table 2, you can see that you may decide to choose 99214 over 92014 if both are met; likewise, 99213 is the winner when compared to 92012.

One of the quirks in the MPFS Final Rule: The eye code payment exceeds the roughly comparable E/M codes for these pairs only for the six counties in/near the city in the San Francisco Bay area. In all other areas, the E/M code is the slight or clear winner.

Keep in mind that failure to raise your fees sufficiently means that a payer (Medicare or otherwise) will only pay you what you ask — not what they might otherwise have paid if you charged a bit more. Evaluate your charges for exams (and other services) annually so you can take advantage of the increases.

Understand and implement

Payment for eye exams codes changed in 2021 for Medicare, and most payers may eventually follow for this year. Your contracts usually specify payment as a percentage of the MPFS, but individual payers can vary. As a result, you might choose differently than you do now, but only if you understand and implement it properly. Check your 2021 fees to ensure full payment.

Lastly, stay safe. And, as always, “good coding to you.” OP