Coding Question of the Month: January 2020

January 2020: Evaluation and Management Changes for 2021

On February 9, 2019, the Current Procedural Terminology (CPT) Editorial Panel approved revisions to the Evaluation and Management (E/M) office visit CPT codes to address some of the issues related to administrative burden for physicians in the U.S. 

The primary goals of the revisions are: 

- To decrease administrative burden of documentation 
- To decrease the need for audits by adding and expanding key definitions and guidelines
- To decrease unnecessary documentation in the medical records

The CPT coding changes include:

1. Reducing the number of levels to 4 for office/outpatient E/M visits for new patients, while retaining 5 levels of service for established patients
2. Elimination of history of present illness (HPI) and physical examination as elements of code selection
3. Physicians can choose to use either Medical Decision-making (MDM) or time to determine the level of E/M visits 
4. Revised  MDM process and guidelines
5. Revised E/M code descriptions
6. Revised times 
7. Revised Introductory and E/M section guidelines 

Review of Changes

1. Reducing the number of levels to 4 for office/outpatient E/M visits for new patient visits, while retaining 5 levels for established patient visits

Code 99201 will be deleted. Both 99201 and 99202 have straightforward MDM and differ by history and exam elements only.

2. Elimination of history of present illness (HPI) and physical examination as elements of code selection

As a best practice, providers should continue perform and document clinically relevant H&Ps.

3. Determining the level of E/M visit based on MDM or time 

Physicians are allowed to choose whether their code selection will be based on MDM or time.  This determination may vary per each individual patient. 
For code selection primarily based on time, the time used is total time on the date-of-service which consists of total physician/qualified health care professional (QHP) time on the date of service. This includes both face-to-face and non face-to-face time. 

Extensive edits were made to the MDM elements for code selection.  See the updated MDM table.

4. Revised process of medical decision making (MDM)

The current CMS Table of Risks was used as a foundation, although elements of MDM were revised. The new term of “independent historian” was added;  term “mild” was removed from description of level of exacebration. Amount and/or Complexity of Data element was re-defined with Categories 1-3 added to each level of MDM from Low to High. See the updated MDM table.

5. Revised code descriptions

Code definitions for E/M visits 99202-99215 were revised due to the removal of requirements for key components of history, and exam. 

99202      Office or other outpatient visit for the evaluation and management 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 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.

99204      Office or other outpatient visit for the evaluation and management 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 evaluation and management 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 99XXX)

99211     Office or other outpatient visit for the evaluation and management 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 evaluation and management 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 evaluation and management 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 evaluation and management 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 evaluation and management 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 99XXX)

New total time minutes were added to replace existing face-to-face typical  times. In addition, a new shorter prolonged services code 99XXX was created  to capture physician/QHP time in 15-minute intervals for reporting additional time with codes 99205 and 99215 only. For prolonged services codes, see Guideline changes.

6. Revised times

Time increased for each code and will now be expressed as a range. Typical time was replaced by total time spent by physician/qualifies health care professional (QHP) on the date of service.

The AMA uses the following definition of time:

Total time on the date of the encounter (office or other outpatient services [99202-99205, 99212-99215]): For coding purposes, time for these services is the total time on the date of the encounter. It includes both face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the date of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).

Physician/other qualified health care professional time includes the following activities, when performed:

  • preparing to see the patient (eg, review of tests)
  • obtaining and/or reviewing separately obtained history
  • performing a medically appropriate examination and/or evaluation
  • counseling and educating the patient/family/caregiver
  • ordering medications, tests, or procedures
  • referring and communicating with other health care professionals (when not separately reported)
  • documenting clinical information in the electronic or other health record
  • independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • care coordination (not separately reported)

7. Revised guidelines

New definitions for the elements of medical decision making  for office or other outpatient services were added to guidelines (eg, Problem, Problem addressed, Minimal problem, Self-limited or minor problem, Independent historian(s)). For the full list of definitions, see Guideline changes.

The listed CPT E/M changes will not be implemented until January 1, 2021. However, medical offices and health care organizations are recommended to start educating themselves and staff in advance. To support the implementation of these revisions, the American Medical Association (AMA) has launched an educational initiative via the AMA website to provide up-to-date information and resources on the E/M code revision efforts. The information is available at www.ama-assn.org/cpt-evaluation-and-management. The additional open to public education is available through the online AMA EdHubTM platform over the coming year.

Another of the AMA’s initiatives is publishing a series of E/M articles in the CPT Assistant during the transition period. Topic ideas for E/M articles can be submitted to CPT Assistant at  cptassistant@ama-assn.org.

For further updates, please check ACOG’s webpage at www.acog.org.

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