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

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

The AMA CPT Editorial Panel has recently approved revisions to the Current Procedural Terminology (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.

The most significant 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 re-document 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.
  • Extensive E/M guideline additions, revisions, and restructuring deletion of code 99201 and revision of codes 99202–99215. For each code descriptor for these services in CPT, all references to level of history and physical examination are removed. Instead, there must be a medically appropriate history and/or physical examination and a specified level of medical decision-making (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 (more than 50%) the encounter 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. This category 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. For more information on this factor, the American Medical Association (AMA) website has more information.
  • Risk of complications and/or morbidity or mortality.

MEDICARE PHYSICIAN FEE SCHEDULE 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 2021 Medicare total payment.

CPT Code Descriptor 2021* Total
Payment
2020**
Total Payment
Difference $ % Difference
99202 Office/outpatient visit, new, Level 1  $            69.04  $             46.56  $            22.48 48%
99202 Office/outpatient visit, new, Level 2  $            69.04  $             77.23  $            (8.19) -11%
99203 Office/outpatient visit, new, Level 3  $          106.14  $           109.35  $            (3.21) -3%
99204 Office/outpatient visit, new, Level 4  $          159.36  $           167.09  $            (7.73) -5%
99205 Office/outpatient visit, new, Level 5  $          210.66  $           211.12  $            (0.46) 0%
99211 Office/outpatient visit, established, Level 1  $            22.26  $             23.46  $           (1.20) -5%
99212 Office/outpatient visit, established, Level 2  $            54.20  $             46.19  $              8.01 17%
99213 Office/outpatient visit, established, Level 3  $            86.78  $             76.15  $            10.63 14%
99214 Office/outpatient visit, established, Level 4  $          122.91  $           110.43  $            12.48 11%
99215 Office/outpatient visit, established, 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 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 RVUs for the office E/M codes.  Medical societies, including ISASS, 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.

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

CMS has links and information as well, which can be accessed at the following links: