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Orthopaedic Provider Coding Trends After 2021 Changes to the Current Procedural Terminology Evaluation and Management

Dylan Koolmees¹, Micah T White, Jeffrey Murphy

¹From the Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center (Dr. Koolmees, Dr. White, Dr. Azar, Dr. Bettin), Memphis, TN, and the Murphy Statistical Services (Mr. Murphy), Warsaw, IN.

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|December 26, 2024

Summary

Orthopaedic coding practices saw a significant increase in E&M code levels for new and established patients following guideline changes. This trend persisted for two years, indicating a lasting impact on billing.

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Area of Science:

Healthcare Administration
Medical Billing and Coding
Orthopaedic Surgery

Background:

Changes to the 2021 Current Procedural Terminology Evaluation and Management (E&M) Centers for Medicare and Medicaid Services guidelines were implemented.
Training was provided to healthcare providers on these new E&M coding guidelines.

Purpose of the Study:

To assess the impact of the 2021 E&M guideline changes on orthopaedic coding practices.
To determine if changes in coding levels were sustained post-implementation.

Main Methods:

Retrospective analysis of outpatient encounters from December 2020 to January 2023.
E&M codes for new and established patients were categorized by complexity level.
Coding data was grouped by provider and analyzed across specified time points.

Main Results:

A statistically significant increase in E&M coding levels for both new and established patients was observed immediately after guideline changes (P < 0.001).
For new patients, the utilization of Level 4 codes increased from 16% to 54%, and Level 5 codes from 3% to 6% (P < 0.0001).
This elevation in higher-level coding was sustained for new patients over the two-year study period.

Conclusions:

The updated E&M guidelines led to a statistically significant shift towards higher coding levels for both new and established patients.
The observed changes in coding practices were maintained for a duration of two years.