Latest Update – Major changes on the horizon to E/M visit medical coding in 2021

AIMA Medical Coding E/M Visits RCM

The AIMA medical coding team have centralized the very latest updates for US-based physician practices. The new changes, effective from January 2021, relate to E/M visit medical coding. Read on to find out more, saving you hours of research and reducing potential coding errors.

For purpose of this article E/M stands for “evaluation and management”. E/M coding is the process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing

The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) are planning significant revisions to office and outpatient E/M codes 99201-99215 in 2021. Adherence to E/M documentation guidelines consumes a considerable amount of physician time and does not reflect the actual work of physicians.

As an alternative to Medicare’s plans, AMA developed new guidelines and code descriptors for office and outpatient E/M codes. All of this means big changes are ahead in the coding, documentation and payment of these evaluation-and-management services.

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
    • Allowing physicians to choose whether their documentation is based on medical decision-making or total time. This builds on the movement to better recognize the work involved in non-face-to-face services like care coordination.
    • 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 exam elements are recorded, they do not factor into the level of service.

Current Procedural Terminology (CPT) changes

The American Medical Association (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.

Time as a determinant of level of service

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 percent) 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 the encounter.

MDM as the prime determinant of level of service

It is expected that the conversion to MDM as a basis for the level of coding will require some planning and preparation on the part of qualified healthcare providers. 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

Number and complexity of problems addressed at the encounter

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 self-limited or minor problem to 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. These will be published in CPT for 2021 but are available now for providers to review.

Amount and/or complexity of data to be 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. Levels include minimal or none, limited, moderate, and extensive. Data are divided into three categories:

  • category 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)

Risk of complications and/or morbidity or mortality

This 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—for example, risk, morbidity, social determinants of health, and drug therapy requiring intensive monitoring for toxicity.

Once the level of the presenting problem is established, 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.

Prolonged and Complex Services

When you start using the revised E/M codes for office/outpatient visits in 2021, watch for opportunities to report add-on codes that represent long and complicated services.

Prolonged services: The MPFS 2020 final rule confirms that Medicare will allow use of +99XXX in 2021 for prolonged services. The primary service (99205 or 99215) and the +99XXX work will have to occur on the same date.

Because of the creation of +99XXX, Medicare indicated in the 2020 MPFS final rule that it will not create the new “extended visit” G code described in the 2019 MPFS final rule.

Complex visits: The 2019 final rule also included a plan to create two new G codes to represent the visit complexity inherent to certain services, with one code for designated specialists and a second code for primary care providers. The 2020 MPFS final rule changed that, adopting a single new G code instead, temporarily known as GPC1X:

Medicare Physician Fee Schedule (MPFS)

CMS announced in the 2020 Medicare Physician Fee Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommended relative values for 2021 CPT E/M codes. Of note, there will be modest payment increases for most office E/M codes beginning January 1, 2021, which may benefit those who manage patients with complex conditions.

For more detailed information about our medical coding services, please contact the AIMA team today. We are here to help and support US physician practices, laboratories and surgical centers with our expert revenue cycle management solutions.