As of January 1, 2021, there will be significant changes to the office and outpatient Evaluation and Management services (CPT codes 99202-99215) for both new and established patients. Through these many years, coders utilized 1995 and 1997 E/M guidelines which is basically a point based system of coding that assigns a particular point value for each service provided. For 2021, CMS will move from this point based system for history, exam and medical decision making, to a medical necessity based system.
Before looking into the detailed review, let’s see the highlights of the E/M changes 2021:
Highlights of E/M changes 2021:
- Changes to E/M documentation apply to CPT 99202-99205 and 99211-99215 only.
- History and examination as key elements for code selection will be eliminated.
- New changes to MDM and total time.
- Deletion of CPT 99201 (level 1, new patient)
- New code 99XXX for “addition of a 15-min prolonged service.
- New HCPCS code GPCX1 for “visit complexity”.
- Per AMA, the changes to E/M code selection apply to Medicare, Medicaid and all commercial payers.
- Commercial payers are not required to adopt HCPCS code for visit complexity.
Elimination of history and examination key elements in the code selection:
All these years, coders considered history, examination and medical decision making as key elements in selecting a level of E/M service. The history and examination were further classified into problem focused, expanded problem focused, detailed and comprehensive based on several parameters. Although these are necessary factors to report an E/M visit, starting Jan 1, 2021, these key elements WILL NOT factor into the code selection. Instead, the code level will be determined solely by the medical decision making or time.
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
New criteria of MDM or total time as the basis of E/M level code selection:
The new E/M coding rules in 2021 allows the physicians to choose whether their documentation is based on MDM or total time. There are specific changes to definitions, terms, and a new MDM table is also created for the E/M code changes 2021.
Medical decision-making elements:
In 2021, the MDM elements associated with codes 99202-99215 will consist of three components:
- The number and complexity of problems addressed during the E/M encounter.
- Amount and/or complexity of data to be reviewed and analyzed AND
- Risk of complications and or morbidity or mortality of patient management.
In order to select a level of E&M service, two of the three elements must be met or exceeded. A new medical decision-making table is also prepared to further outline the criteria for the E&M code level selection.
A major change has occurred in terms of the definition and the deciding factor of time usage in 2021.
The definition of time associated with CPT ® codes 99202-99215 has been revised from the typical face-to-face time to total time spent on the day of the encounter. This redefinition of time allows you to use the total time that includes both the face-to-face and non–face-to-face services like care coordination and record review.
In 2021, the total time corresponding to CPT codes 99202-99215 have been defined at specific intervals as below:
New patient codes:
- 99202: 15-29 minutes
- 99203: 30-44 minutes
- 99204: 45-59 minutes
- 99205: 60-74 minutes
Established patient codes:
- 99212: 10-19 minutes
- 99213: 20-29 minutes
- 99214: 30-39 minutes
- 99215: 40-54 minutes
The current guidelines instructs the coders to use the time as the deciding factor for the E/M code only when the counselling, coordination of care or both contribute to more than 50 percent of the encounter. However, the 2021 changes for 99202-99205 and 99212-99215 allows the coders to use the time as the deciding factor for the code choice even when the counselling and coordination of care do not dominate the visit.
Deletion of CPT code 99201:
The 2021 CPT® code set will not include new patient level 1 code 99201 due to its low utilization and also based on the fact that both 99201 and 99202 are associated with straight forward medical decision making.
New prolonged services CPT code:
A new prolonged services code 99XXX (with or without direct patient contact) has been created for use only with office/outpatient E/M visits. This is a time-based billing code used to represent time beyond the highest E/M code in the appropriate code set. (Either CPT code 99205 or 99215). To report a unit of 99XXX, 15 minutes of additional time must have been attained. Do not report 99XXX for any additional time increment of less than 15 minutes.
CMS plans to reimburse 99XXX 0.61 RVUs (about $22).
An important note is that the new prolonged service can only be reported under the following circumstances:
- When the E/M service has been selected based on time alone and not medical decision making.
- When the total time of a level 5 service (either 99205 or 99215) has been exceeded.
New HCPCS code GPC1X:
CMS also planned to add a new HCPCS add-on code as of Jan. 1, 2021 which can be reported with all levels of E/M office/outpatient codes. This new add-on code describes the additional work and resource costs associated with the ongoing care of single, serious, or complex chronic conditions.
CMS plans to reimburse GPC1X at 0.33 RVUs (about $12)
GPCX1 – Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition.
The changes to the E/M office/outpatient CPT codes and guidelines for new and established patients apply to the below payers:
All traditional Medicare and Medicare Advantage plans
· Medicaid, and
· All commercial payers.
However E/M HCPCS codes apply to Medicare, Medicare Advantage plans, and Medicaid only. Commercial payers are not required to accept HCPCS codes.
Happy learning! Happy Coding!