AMA Announces Updated CPT codes and Instructions for E/M Office Codes for 2021

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AMA Announces Updated CPT codes and Instructions for E/M Office Codes for 2021

The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel recently approved revisions to the CPT Evaluation and Management (E/M) office or other outpatient services codes, which will have significant implications on coding and documentation for these vital services. The changes are scheduled to go into effect January 1, 2021. In addition, CMS has approved updated Relative Value Unit settings for the E/M code set.

The CPT changes are designed to reduce administrative burden and more accurately capture physician work involved in providing the services.

Previously established changes include:

  • For an outpatient visit with an established patient, a provider can record only what has changed since the last visit and need not re-record the history and examination if there is documentation that the practitioner reviewed and updated the information in the medical record.
  • For an outpatient visit with a new or established patient, the billing provider does not need to redocument a chief complaint or history that was recorded in the medical record by ancillary staff. This includes the chief complaint and any other part of the history, history of present illness, past family social history, and review of systems. The billing provider can review the information and update as necessary.
  • The billing provider should document in the medical record that information entered by ancillary staff or the patient has been reviewed.

More extensive changes will go into effect on January 1, 2021, including:

  • extensive E/M guideline additions, revisions, and restructuring deletion of code 99201 and revision of codes 99202–99215
  • code level selection should be based on:
    • medical decision-making (MDM) or total time on the date of the encounter
    • creation of a 15-minute prolonged service code to be reported only when the visit is based on time and after the total time of the highest-level service (e.g., 99205, 99215) has been exceeded.
    • Note: Although the history and physical examination elements are recorded, they do not factor into the level of service.

The AMA has created new CPT code descriptors for office or other outpatient services (new and established patients) that can be based upon the level of MDM or the time spent by the provider on the encounter.

For each code descriptor for these services in CPT, all references to level of history and physical examination are removed. Instead, it is specified that there must be a medically appropriate history and/or physical examination and a specified level of MDM.

For providers who wish to bill by time, the length of time corresponding to each level of visit is specified. Note that the current time rules for coding apply when counseling and/or coordination of care dominates the encounter (more than 50%) and includes only face-to-face time in the office. Starting in 2021, providers who wish to code by time spent may include all related activities on the day of encounter.

MDM has always been part of the algorithm for choosing a level of service but will now be the sole determinant of level of service (unless the provider intends to bill based on time).

MDM in 2021 will be based on:

  • number and complexity of problems addressed
  • amount and/or complexity of data reviewed and analyzed
  • risk of complications and/or morbidity or mortality

The greater the number and complexity of problems addressed at the encounter, the higher the applicable level of decision-making. This ranges from straightforward to low, moderate, and high. Several specific problem level options are listed. They range from a self-limited or minor problem to an acute or chronic illness or injury that poses a threat to life or bodily function. For many physicians, it may not be clear what constitutes a “self-limited or minor problem.” For this reason, specific definitions have been developed by the AMA and CPT so as to limit confusion.

The category regarding the amount and/or complexity of data to be reviewed and analyzed attempts to quantify the amount of data, efforts to gather data, and communications utilized to evaluate a patient. Collection of more data leads to a higher level of MDM. Levels include minimal or none, limited, moderate, and extensive. Data are divided into three categories:

  1. tests, documents, orders, and review of prior external note(s) from each unique source or independent historian(s)—each unique test, order, or document is counted to meet a threshold number category
  2. independent interpretation of tests not reported separately category
  3. discussion of management or test interpretation with external physician/other qualified healthcare provider/appropriate source (not reported separately)

For more information on how to determine the amount and/or complexity of data, the AMA website has more information: [insert link here]

Risk of complications and/or morbidity or mortality is an assessment of the relative danger of patient management, whether from treatment or further work-up. Levels are minimal, low, moderate, and high. Some treatments are relatively risk-free, such as over-the-counter medicines and dressing changes. Some are highly risky, such as a decision about emergency major surgery. To estimate the risk of complications, morbidity, or mortality, it may be helpful to become familiar with the definitions of relevant terms—for example, risk, morbidity, social determinants of health, and drug therapy requiring intensive monitoring for toxicity. The definitions are available on the AMA website. Once the level of the presenting problem is established, the data are reviewed, and risk management is determined, the overall level of MDM can be determined. To qualify for a particular level of MDM, two of the three elements for that level of decision-making must be met or exceeded. That will determine the level of E/M service.

It is clear that this new method of determining the level of E/M service will require major changes to physician behavior and documentation. Providers will need detailed instructions, system changes, and practice using the new E/M codes.

These changes apply only to outpatient visits, so don’t throw away note templates. The old system of documentation is still required for consultations, emergency room visits, and inpatient visits. The old system relied on documentation of a series of bullet points for history and physical examination to support a level of service. The new system for 2021 relies on documentation of bullet points for diagnoses or treatment options, amount and complexity of data reviewed, and risk of complications. Although CMS will implement increased work values for E/M codes performed in the outpatient setting, the increases will not be applied to visits bundled into 10- and 90-day global procedure codes.

What can be done to prepare for these changes?

  • Learn about the proposed changes by reading online, attending coding courses, and watching webinars.
  • Determine whether your electronic health record templates need to be changed to de-emphasize bullet points for history and examination and emphasize elements of MDM.
  • Become familiar with the definitions of problem types, risks, and other elements of services that will be needed to substantiate levels of MDM.
  • Learn to routinely document items within notes that will be used to score MDM, including ordering tests or x-rays, interpreting tests and x-rays, requesting review of outside documents, having discussions with other healthcare providers, and using independent historians aside from the patient.
  • Test-drive some notes to see how they would score using the new MDM parameters.

UPDATED CPT DESCRIPTORS

The updated CPT descriptors are as follows:

New Patients

  • 99201 has been deleted. To report, use 99202.
  • 99202: Office or other outpatient visit for the E/M of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision-making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
  • 99203: Office or other outpatient visit for the E/M 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.
  • 99204: Office or other outpatient visit for the E/M of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
  • 99205: Office or other outpatient visit for the E/M of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision-making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter. (For services 75 minutes or longer, see Prolonged Services 99354)

Established Patient

  • 99211: Office or other outpatient visit for the E/M of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.
  • 99212: Office or other outpatient visit for the E/M of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision-making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
  • 99213: Office or other outpatient visit for the E/M of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision-making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
  • 99214: Office or other outpatient visit for the E/M of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
  • 99215: Office or other outpatient visit for the E/M of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision-making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter. (For services 55 minutes or longer, see Prolonged Services 99354.)
  • 99354 Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour. (List separately in addition to code for outpatient E/M or psychotherapy service, except with office or other outpatient services [99202-99215].) (Use 99354 in conjunction with 90837, 90847, 99241-99245, 99324-99337, 99341-99350, 99483.) (Do not report 99354 in conjunction with 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99415, 99416)
  • 99355: Each additional 30 minutes. (List separately in addition to code for prolonged service.) (Use 99355 in conjunction with 99354.) (Do not report 99355 in conjunction with 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99415, 99416)

MEDICARE PHYSICIAN FEE SCHEDULE PROPOSED VALUES

CMS, in the 2021 Medicare Physician Fee Schedule Final Rule, published their recommended changes in payment for the revised office E/M codes.

The table below shows current (2020 Medicare total payment) and the proposed 2021 Medicare total payment.

CPT Code Descriptor 2021* Total
Payment
2020**
Total Payment
Difference $ % Difference
99202 Office/outpatient visit, new patient, Level 1 $69.04 $46.56 $22.48 48%
99202 Office/outpatient visit, new patient, Level 2 $69.04 $77.23 $(8.19) -11%
99203 Office/outpatient visit, new patient, Level 3  $106.14 $109.35 $(3.21) -3%
99204 Office/outpatient visit, new patient, Level 4 $159.36 $167.09 $(7.73) -5%
99205 Office/outpatient visit, new patient, Level 5 $210.66 $211.12 $(0.46) 0%
99211 Office/outpatient visit, established patient, Level 1 $22.26 $23.46 $(1.20) -5%
99212 Office/outpatient visit, established patient, Level 2 $54.20 $46.19 $8.01 17%
99213 Office/outpatient visit, established patient, Level 3 $86.78 $76.15 $10.63 14%
99214 Office/outpatient visit, established patient, Level 4 $122.91 $110.43 $12.48 11%
99215 Office/outpatient visit, established patient, Level 5 $172.27 $148.33 $23.94 16%
99354 Prolonged services, first 30 min $120.97 $132.09 $(11.12) -9%
99355 Prolonged services, additional 30 min $90.33 $100.33 $ (10.00) -11%
*2021 Proposed Conversion factor=32.26
**2020 Conversion Factor=36.09

These calculations are based on the announced Medicare conversion factor of 32.26 which is an 11% reduction from the current Medicare conversion factor. This is due to CMS applying budget neutrality from the increased relative value units for the office E/M codes. Medical societies, including ISSAS, have strongly advocated to CMS to maintain the current conversion factor. If it is maintained at the 2020 level of 36.09, the payments for E/M procedures would see further increases.

AMA AND CMS RESOURCES

The AMA has posted several helpful PowerPoint presentations and summary documents. Please see the following links for more information and resources from the AMA.

In addition, CMS has links and information. Please see the following links for more information and resources from CMS.