Summative Assessment: APRNs: Navigating Third-Party Payor Rules Case Study

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On January 1, 2021, significant Evaluation and Management (E/M) Codes went into effect that affect providers working in the outpatient setting. The AMA was instrumental in making these revisions that put “patients over paperwork” with the goal of removing obstacles preventing providers from spending quality time with patients.

Prior to these changes, clinicians spent valuable time away from the patient tabulating elements of the history and physical exam to justify the level of service.

The process has been simplified allowing clinicians to bill based on either Medical Decision Making (MDM) or Time. Reimbursement also increased for many E/M codes.

As the FNP in the practice, your office manager has tasked you to present a synopsis of the 2021 billing changes at the next practice meeting. She has requested you create 700 words, references (8 to 10 references), and a detailed notes outlining the key points for billing using MDM and Time in the clinic practice setting. Include the following:

• Explain the criteria that differentiates a new patient from an established patient.
• Explain the clinician rationale in the decision to choose either MDM or Time as the E/M codes to identify a level of service.
• Identify specific activities allowed when using Time as the E/M code.
• List the 3 elements considered when using the MDM.
• List the 4 types of MDM that are recognized, including the E/M numerical code.
• Describe in 1 sentence an example of a patient encounter that reflects each level of MDM.
• Extract the element(s) of the MDM criteria that reinforce the example.
• Watch the introductory video before you begin.

Refer to CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes for guidance during this assignment.