What Is Changing for E/M Codes in 2021: Are You Prepared?

November 2020 – Vol. 39, No. 10

As reported in the June Bulletin, changes to the Current Procedural Terminology (CPT®) coding structure for office or outpatient evaluation and management (E/M) services will take effect on January 1, 2021. After proposing and revising changes to E/M documentation and payment in 2019 and 2020, the 2021 Medicare Physician Fee Schedule proposed rule, released by the Centers for Medicare and Medicaid Services (CMS) on August 4, includes updated policies and rates for these services.

Highlights of the proposed rule include:

  • Withdrawal of a 2019 plan to pay a blended rate for level 2-4 visits. CMS will instead implement revised E/M code definitions developed by the American Medical Association (AMA) CPT Editorial Panel starting January 1, 2021.
  • Adoption of revised and increased work relative value units (RVUs) for E/M services based on recommendations from the AMA Relative Value Scale Update Committee (RUC).
  • Revaluation of certain other services deemed analogous to office E/M services.

Practitioners and billers need to know that the new E/M codes include revisions to the CPT descriptors for codes 99202-99215 and documentation standards. Additionally, in the proposed rule, CMS extends some of the telehealth flexibilities enacted during the COVID-19 public health emergency (PHE).

Major E/M changes for 2021 include:

  • Eliminating history and physical exam as elements for code selection.
  • Allowing physicians to choose whether their documentation is based on medical decision making (MDM) or total time on date of service.
  • Modifying MDM criteria to move away from simply adding up tasks to focusing on tasks that affect the management of a patient’s condition.

The new documentation requirements will be based on the traditional format of subjective, objective, assessment, and plan in which physicians document what the patient was there for (subjective), what was learned from their history and exam (objective), what the physician assessed to be the problem, and the plan for resolving it.

Beginning in January, physicians will have a choice between whether their documentation will be based on MDM or total time. The regulations define “time” as minimum time, not typical time, and this represents total time on the date of service. This definition builds on the movement over the last several years by Medicare to recognize the work involved in non-face-to-face services such as care coordination. There is a limitation on this definition as it only applies when code selection is primarily based on time and not MDM.

MDM

If MDM is used to determine the E/M code for the outpatient visit, the factors a physician must weigh depend on site of service. If the evaluation is in the office setting, the factors in MDM include number and complexity of problems addressed, amount and/or complexity of the data reviewed and analyzed, and risk of complications and/or morbidity of patient management. If the evaluation is in an inpatient setting, factors include number of diagnoses or management options, amount and/or complexity of data to be reviewed, and risk of complications and/or morbidity. Additionally, evaluation and billing for inpatients has not changed.

Time

If time spent on the encounter is used as the determinant for the CPT code billed, the time values will change next year from typical time used to total time used. CPT code 99201 will be deleted, effective January 1, 2021. For new patient codes, times begin at 15–29 minutes for CPT code 99202 and then advance in 15-minute increments with 99205 assigned 60–74 minutes. For existing patients, the time element was removed from CPT code 99211. For CPT code 99212, time for the encounter will be 10–19 minutes. Ten-minute increments are used for codes 99213 and 99214. CPT code 99215 has a 15-minute time frame and is utilized for exams 40–54 minutes in duration.

If these time frames do not reflect enough time to describe the encounter, there will be a new code for CPT codes 99205 and 99215 for those reporting based on time. Code 99417 will be used in 15-minute increments when the visit takes longer than the times allowed in the new codes. Prolonged services of less than 15 minutes should not be reported. Code 99417 can be reported multiple times for the same visit. For example, if an encounter takes 90–104 minutes, 99205 should be reported in addition to 99417 being reported twice.

CPT Code 99358

There is an additional CPT code, 99358, that should be utilized for non-face-to-face encounters, usually telehealth, and therefore should not be reported on days when other E/M codes are reported.

Telehealth

The rule includes proposed policy changes to maintain certain elements of the various telehealth flexibilities authorized on a temporary basis during the COVID-19 public health emergency, with some proposals lasting until December 31, 2021, or the end of the calendar year (CY) in which the public health emergency ends, whichever is later. The services CMS is proposing to add to the Medicare telehealth list include GPC1X – Visit Complexity Associated with Certain Office/Outpatient E/Ms, 99417 – Prolonged Services; 99334, 99335 – Domiciliary, Rest Home, or Custodial Care Services; and 99347, 99248 – Home Visits.

CMS is not proposing to continue separate payment beyond the public health emergency for the audio-only telephone E/M services established in the March 31 COVID-19 interim-final rule. However, the agency is seeking feedback on developing coding and payment for such a service. CMS is also proposing to allow direct supervision to be provided using real-time, interactive audio and video technology (excluding telephone that does not also include video) through December 31, 2021. Some private payers have shown interest in making the telehealth changes adopted for the PHE permanent.

The telehealth proposals are subject to change. Any permanent policy changes will be implemented in the Physician Fee Schedule final rule, which is expected to be released around the same time that this article is published. Due to the COVID-19 pandemic, CMS has waived the 60-day delay in the effective date of the final rule and replaced it with a 30-day delay. This means that the final rule will be effective January 1, 2021, even though it may not be published until December 1, 2020.

Check the Bulletin early next year for another update on these and other policies included in the CY 2021 Medicare Physician Fee Schedule that impact the specialty.

Visit the Academy’s Coding Corner, https://www.entnet.org/content/coding-corner, for additional updates on the revised E/M codes, as well as the newest coding and reimbursement tools for members.