2021 CPT Coding Updates

The new year has certainly brought more than its share of coding updates. Here’s a quick round-up of what to know for 2021.

2021 E/M coding updates

After many years of deliberation, 2021 E/M coding has been updated to be based on either medical decision making (MDM) or time as the main criteria for determining the level of service. The extent of history and physical examination are no longer used as elements to determine accurate coding. Still, providers are expected to rely on their professional expertise to decide the relevant information required and document it in the patient history. Outpatient E/M visits will no longer use the 1995 or 1997 guidelines.

Level 1 new patient E/M code 99201 has been eliminated, and 99211 is considered a straightforward diagnosis and treatment – to the extent that the presence of a qualified health professional may not be necessary.

The rest of the levels have been shifted to help make MDM determinations more straightforward:

Code Level of MDM
99202/99212 Straightforward with minor problems and minimal complexity and risk of morbidity
99203/99213 Low with minor problems, limited complexity, and low morbidity risk
99204-99214 Moderate with acute or chronic illness, review of data necessary for diagnosis and/or treatment, and moderate morbidity risk
99205/99215 High with more than one chronic disease with severe exacerbation or progression or acute illness or injury that poses a threat to life or bodily function, an extensive review of data necessary for diagnosis and/or treatment, and high risk of morbidity from additional diagnostic testing or treatment


When time is used as the main element for determining E/M levels, it is critical that exact timekeeping is recorded in the patient record. Time requirements for 2021 E/M coding are as follows:

Level New Patient (minutes) Established Patient (minutes)
1 N/A N/A
2 15-29 10-19
3 30-44 20-29
4 45-59 30-39
5 60-74 40-54

Codes that can be used to indicate prolonged level 5 new and established patient E/M visits, as well as codes to show increased complexity for level 5 visits, have also been added for 2021.

New COVID vaccine codes are tied to the type of vaccine

To track distribution and aid in analysis, codes have been added to indicate vaccine types and vaccine administration:

Code Descriptor Admin Codes Manufacturer
91300 mRNA-LNP, spike protein Dose 1 – 0001A

Dose 2 – 0002A

91301 mRNA-LP, spike protein Dose 1 – 0011A

Dose 2 – 0012A

91302 DNA, spike protein, Oxford 1 vector Dose 1 – 0021A

Dose 2 – 0022A

91303 DNA, spike protein, adenovirus vector Single dose – 0031A Janssen

New COVID vaccine codes will be added as vaccines are approved for use. Check the AMA website for information.

Also note:

CPT 99072: additional supplies and staff time to mitigate transmission of respiratory infection disease

There are many more changes included in the 2021 CPT code set

According to the AMA, there were 329 changes to 2021 CPT coding – including 206 new codes, 54 deleted codes, and 69 revised codes. Many new codes are tied with new technology. For example, CPT 92229 was added for retinal imaging with automated point-of-care (for primary care settings). CPT range 93241-93248 was added to include continuous cardiac monitoring and detection via a patch worn by patients.

There will be more CPT coding updates in 2021

Keeping track of CPT coding changes while managing a healthcare organization impacted by the COVID pandemic may be challenging in the year ahead. In addition to regularly monitoring CMS and AMA updates, MACs and payers will be publishing their guidance about coding and proving medical necessity. Staying on top of the latest changes will be critical to your practice’s financial health – using the right partner for practice management software and billing makes it easy. Contact Virtual Revenue Solutions today at (412) 424-2265 or visit vrsmed.com to learn how we can help keep you informed of coding changes, optimize MIPS, streamline claims, and maximize revenue.

The Impact of Fee Schedules

The Impact of Fee Schedules

Fee schedules play a critical role in reimbursement for every physician practice. Many physicians, however, don’t know what, exactly, a fee schedule is, and how their own is kept up-to-date.

Oftentimes, when we speak with physician practices and ask about their fee schedules, the physician acknowledges that they have a fee schedule, but that they have no idea who created it, maintains it, or even where it originated.

So, let’s start at the beginning…

A fee schedule is a complete listing of all the fees used by an insurance carrier to pay physicians and other providers of healthcare services/products. This comprehensive listing provides a maximum reimbursement that each carrier will pay to physicians for their services.

Often, many commercial/managed care carriers will base their fee schedules off of the CMS’ Physician Fee Schedule, and so CMS is frequently referenced as the leading authority for the average reimbursement for medical services. Each insurance carrier that a physician/physician group is credentialed and participating with will have their own fee schedule that is a part of their contract with physicians for reimbursement.

Fee schedules are also used internally by physician practices for both cash billing and carrier billing for services provided. These fee schedules are created and maintained by the physician and their billing staff, and are used to ensure that the physician is collecting the maximum amount of revenue allowed by the carrier for each date of service.

Why is all of this important to physicians?

Let us provide an example…

Say you see a new patient and your internal fee schedule (what you bill the insurance company) is set at $75 for a new patient office visit CPT. The insurance carrier receives and processes the claim and reimburses you the entire $75. That’s great, right? Not always.

Total reimbursement by an insurance carrier for a billed amount often signals that the billed amount may be too low, and that the provider may be losing out on the maximum allowable reimbursement for that CPT; this is an indicator that the practice needs to review their billing fee schedule and perhaps increase the charged amount on certain CPT codes.

Conversely, imagine that the same patient has returned for another visit. You’ve updated your fee schedule and are confident that you will now collect the maximum you are owed for the service. Your billed amount is now set at $150 for this service. The insurance company receives and processes this new claim; however, this time only reimburses you for $25 of the billed amount. What happened? Is your fee schedule now set too high or did the insurance company reimburse too low?

Unless you have a copy of your fee schedule with that carrier or understand what the average reimbursement for that CPT is, it will be difficult for your biller to know why the claim was reimbursed at such a low rate.

These two scenarios are good representations of what we frequently encounter when we consult with various physician practices and organizations. It is not uncommon to uncover significant lost revenue, either because the claim was billed at too low an amount, or because the biller did not have the time, information and resources (system set up) necessary to make sure each claim was being paid correctly.

It is critical that physicians and their managers recognize this crucial piece of the billing cycle, and work to make certain that it is kept up to date within their practice management system.

If you have questions or need extra help with your fee schedule and/or other areas impacting your revenue cycle, we can provide assistance.

Moving Forward: Managing the Repercussions of COVID-19

As the country reopens from the COVID-19 shutdown, healthcare organizations are gradually emerging from the most extensive mass disruption to healthcare delivery ever known. In March, the CDC recommended postponing all elective surgeries during a nationwide lockdown. Additionally, practitioners of all specialties saw volumes drop, leading to an unprecedented plunge in revenue that resulted in 1.4 million healthcare jobs lost in April alone.

COVID-19 caused shortages of PPE, which meant that some providers were not fully equipped to protect themselves from the virus and contracted the disease. Climbing infection rates and death tolls made daily headlines. The worst may not be over; recent reports warn Americans to brace themselves for a second wave.

Where do healthcare practices go from here? There are many factors to consider, ranging from ensuring the health and safety of patients and staff, to reviewing finances to keep the practice open, to getting ready to be hit by the virus again. Here are some practical suggestions to get you started moving in the right direction.

Ensuring the health and safety of patients and staff – adjusting workflows

Although patient volume should steadily grow in the coming weeks, many patients are still reluctant to visit their healthcare provider. Healthcare organizations are aware that some members of staff may have concerns about returning to work. One answer to assure health and safety is to adjust workflows mindful of three categories: utilizing technology, maintaining social distancing, and enacting cleaning and visit protocols.


Many providers are using telehealth to treat patients without seeing them in person, saving PPE and eliminating possible exposure in the office. Pre-visit COVID-screening phone calls are another useful tool to warn providers of potential cases. Some offices have chosen to ask patients suspected of having COVID remain in their cars during specimen retrieval, so the patient never enters the office. Phone or video visits can also be used by support staff for histories of present illness and health histories, so they don’t need to be done in-person, saving time (and limiting exposure) while the patient is in the office.

Social distancing

The use of ‘pod’ treatment areas is a hospital concept that can be applied to outpatient settings. Some offices are designating staff to COVID and non-COVID workstations. The idea is to keep staff and supplies completely separate, thereby lowering the risk of cross-contamination. Limiting staff and patient entrances and exits is another strategy to maintain social distancing (and screen for COVID before entering the building). Both patient and staff areas should have seating at least six feet apart and consider using partitions in places where it makes sense, such as the front desk.

Cleaning and visit protocols

Communicating to your patients about visit protocols, including enhanced cleaning and disinfection, may help patients feel more comfortable during their appointments. A bonus is that it is likely to help your staff feel more comfortable as well. Visit the CDC website for printable notices about stopping the spread of COVID-19 and educational materials to display in your office. Some offices have enacted ‘split shifts’ to accommodate new cleaning measures; for example, half a shift is dedicated to regular duties, while the second half is used for cleaning.

Review finances to prepare for future fluctuations

Unfortunately, many offices will begin operating with a diminished workforce due to lay-offs. As volume starts to increase, the need for staff will rise as well. Building financial forecasts will help organizations gauge their readiness to move toward building a ‘normal’ practice. Some financial considerations include:

• Ensuring funding/capital is available for future needs (consider how to minimize the economic impact of a second wave or where you can go for money if needed)

• Review the unforgivable part of the SBA 7(a) PPP loan, note reporting requirements and payment deadlines

• Consider offering payment plans to patients that have become unemployed or uninsured; if you already provide payment plans, review payment options and limits to see if you think they are still appropriate

• Review EOBs to look for trends indicating changes in payer mix and anticipate how changes may affect revenue moving forward

• Consider outsourcing billing to protect your revenue flow; third-party organizations have layers of employees and systems resilient to staffing fluctuations

Also, think about revising your budget based on anticipated volume, historical collection ratios, and payback of deferments and loans. Moving forward will be much easier when you know where you stand.

Get ready for a second wave of COVID-19

Health officials warn that there will likely be a second wave of infections in late Fall of this year. Now is the time to prepare for possible PPE and drug disruptions, as well as renewed stay-at-home orders.

• Avoid future PPE and drug shortages by analyzing consumption and supply since March

• Build a stockpile of PPE that can carry you through the initial stages of a second wave

• Find alternate suppliers of infection control PPE

• Build a list of alternatives to commonly prescribed drugs at your practice

• If you are not already using online visits, investigate platforms and consider adding them as a standard service; it will help minimize future patient care disruptions

Many lessons have already been learned since the outbreak of COVID-19, and there are undoubtedly more to come. Practices that continually assess their health and safety protocols, financial stability and preparedness for another emergency put themselves in the best position to weather upcoming challenges.

Using the right partner for practice management software and billing can help you continue operations during uncertain times. Contact us today for a no-obligation discussion at 412.424.2265 or email info@vrsmed.com.

Are you working harder, not smarter?

Examining your gross and net collections ratios will tell you

Have you been in this scenario?

You’ve gone through your financial reports again and again, trying to figure out why your practice is making less money. The problem is everything looks the same. There is no increase in denials, chargebacks or write-offs. Your patient visits have remained steady. Where do you go to find answers?

According to Alyse Danley, Revenue Account Manager at Virtual Revenue Solutions, there are two ratios you should check: your gross collections ratio (GCR) and your net collections ratio (NCR). “Understanding these numbers can help you gauge your performance and forecast future earnings,” said Danley. “When you look at these numbers in conjunction with your fee schedule, you can understand adjustments you may need to make to put your practice back on track.”

Understanding your gross collections ratio (GCR)

Total payments/charges

One question this ratio answers is how close you are to your payers’ rates. Monitor your top codes to confirm that you are in line with your practice’s established fee schedule ratio (typically around 150% of Medicare allowable amount or above). If your top code fee ratios are smaller than your set ratio, it may be time to renegotiate your rates with payers. Outdated reimbursement rates are often a problem with older practices because operational costs have gone up, but payment rates are stuck in the year the payment contract was signed.

If your GCR is inching-up every month, then it’s time to review your fee schedule and consider raising your rates. There’s a possibility that your fees may be lower than some of your payers’ allowable amounts. Low fees happen more frequently than many realize. Yearly reviews of your fee schedule against payer reimbursement will help avoid this issue.

According to Danley, your GCR is best used for internal measurement. It’s good to be aware of your number every month, but looking at a rolling six-month analysis allows for variances due to seasonality (such as deductibles at the beginning of the year, holiday slow-downs or times of the year when you get particularly busy).

Understanding your net collections ratio (NCR)

Payments – adjustments/ charges

Your NCR measures how well your practice is collecting the money it is owed. Ideally, NCR ratios should be at 95% or above – meaning you have collected 95% or more of possible revenue. This ratio is dependent on many factors, both operational and payer-related, including your mix of carriers, the types of procedures you perform and how quickly A/R is resolved.

If your NCR needs to be improved, or you are seeing large month-to-month fluctuations, there are several questions you should be asking. The answers will help you pinpoint weaknesses and set goals for improvement. They include:

  • Are you carrying A/R past 60 days?
  • Is there an issue with receiving payments?
  • Are payments posted promptly?
  • Do you have a consistent mix of appointments (new patients, sick visits, follow-ups, etc.)
  • Are you performing more or less of your top procedures?
  • Has reimbursement for your top procedures changed?
  • Is there a problem with sending out secondary claims or patient statements?
  • Are there payers having unusual delays in payments?

A change in payer mix may account for variations in your NCR as well, so Danley recommends performing a payer mix review on at least a yearly basis. Isolate your top payers and pull reports showing charges, payments and adjustments for the last twelve months. It may be that payers that reimburse less are a more substantial part of your patient population than a year before. She also recommends periodic reviews of longer data periods (three to five years) to identify macro trends that are hitting your bottom line.

Another useful aspect of knowing your NCR is that it is an excellent metric to use to compare your practice to others. Resources to find comparable data include the MGMA, HFMA and other medical associations. In many instances, you will pay for the reports, but the value of having realistic benchmarks to work toward and simply knowing how your practice is performing against others can make the cost worthwhile.

About Virtual Revenue Solutions

Virtual Revenue Solutions (VRS) partners with Virtual OfficeWare Healthcare Solutions (VOWHS) to provide insight into today’s shifting landscape of medical reimbursement. They identify barriers in your revenue cycle and provide an extra set of hands to your billing team so you can prioritize patient care.

Do you have questions about your GCR or NCR ratios, or concerns about your practice’s overall performance? Contact VRS today at (412) 424-2265 or visit vrsmed.com.





ICD-10 Codes for the Holidays.


Cut your High Rate of Unspecified Coding Denials

Although ICD-10 has been in use for several years, problems with unspecified coding and the subsequent denials they trigger persist. Fortunately, unspecified coding denials can be easy to remedy for coders when they are given the complete picture of the encounter. Unfortunately, clinicians often don’t understand how poor documentation can leave coders with no other choice but to use an unspecified code.

It is essential to understand what unspecified codes say to insurance companies in order to fully understand why they so often trigger denials.

What unspecified codes really mean

In a nutshell, anytime an unspecified code is recorded on a claim, it is telling the payer that the case is so exceptional, it cannot be defined. According to The American Health Information Management Association (AHIMA), documentation must reflect the full extent of clinical knowledge. Therefore, these codes are saying that there is something about the condition that is unknown.

Sometimes unspecified codes are appropriate

There are times when unspecified codes are applicable – for instance, in cases of poisoning when the agent can’t be determined or with certain diseases and viruses. Overall, most providers that are practicing day-in-and-day-out medicine should be using unspecified codes as an exception rather than the rule.

The financial consequence of unspecified coding

Unspecified codes can trigger outright denials that need to be resubmitted and additional documentation requests (ADRs) that are time-consuming to resolve – resulting in increased labor costs. Another costly danger of unspecified claims is the risk of timely filing write-offs when responses to ADRs are delayed.

Considering the root causes of unspecified coding, most claim problems are avoidable.

Documentation omissions often result in unspecified codes

ICD-10 expanded diagnosis codes from the prior ICD-9 set of approximately 13,000 to around 68,000. That means the new codes contain a level of specificity that didn’t exist before the update, and the only way to code to that level of specificity is to have the information documented in the patient record. Generally, some broad categories help define specificity. They include:

  • Laterality
  • Specific body sites
  • Prior history
  • Circumstances (intentional or accidental)
  • Initial or subsequent encounter

Including information about the general categories will often give coders the information they need to code to the highest level of specificity.

Coders need to dig a little deeper

Of course, there are instances when documentation that defines specificity is contained in the patient record, but overlooked by coders. For example, a patient encounter only states shoulder pain, but a radiology report tied to the visit finds a hairline fracture of the right scapula. Therefore, the fracture should be the diagnosis rather than the pain in the shoulder.

In addition to looking through documentation to find answers, it can be helpful for coders to have more than one resource to help code.

Coding resources can help define specificity

There are many resources available to help coders capture the correct ICD-10 code. Free resources to aid coders are available from CMS at https://www.cms.gov/Medicare/Coding/ICD10/ICD-10Resources. However, many practices use coding software for its convenience, accuracy and efficiency.

For example, Centricity® offers a function that uses an easy-to-understand stoplight system to help providers determine if there is an acceptable level of specificity on the claim. A click of the mouse accesses the full list of ICD-10 codes to search. The codes can then be refined further to enhance specificity and can account for clinical attributes such as anatomical site, causative agent, specific episode of care, laterality, etc. A green light appears when billable specificity levels are achieved.

Get to the bottom of your unspecified coding issues

There are some simple, but effective steps you can take to minimize the use of unspecified codes:

1.  Audit denials

Regularly run denial reports to pinpoint problem coding. Plan on tackling the codes with the largest percentages of denials first.

2.  Review documentation

Pull patient records for the selected denied codes to confirm the encounter notes contain all required information for coding to the highest degree of specificity. If critical information is missing from the record, provide training to providers to ensure awareness of the information needed for correct coding. Retrain coders that are missing vital information contained in the patient notes to avoid unspecified codes in the future.

3.  Continually monitor

Coding definitions change and many practices have staff turnover. Continual monitoring of denials and documentation allows corrective action to be taken immediately – keeping labor costs low and revenue flowing.

Want to learn more about how VOWHS can help you avoid unspecified code denials? Contact us today at (412) 424-2260 or visit us at www.vowhs.com.

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