Proposed Evaluation and Management Coding Changes for 2021

By: Lisa Messina, Corporate Compliance Officer

Categories: Industry News, PMG Insights Blog

September 21, 2020

It has taken 30 years, but the AMA and CMS have performed a complete overhaul of the Evaluation and Management (E/M) documentation and coding guidelines and they are set to be implemented January 1, 2021.  The hope is that the burden associated with meeting the 1995 or 1997 guidelines will finally be lifted and patient care will also be improved as physicians spend less time hashing out the coding rules and more time caring for their patients.

There are over 12 dozen E/M categories, but the focus of the proposed changes is on the Office and Outpatient Visit category that includes CPT code range 99201-99215.  This means that while the majority of office visit services familiar to health centers will be impacted, the other E/M services outside that code range will continue to use the existing rules for determining those service levels.

The biggest change to how services in the 99201-99215 range will be coded is the documentation of the history and/or physical exam will not be used to determine the level of service.  This change is a win to providers who have long argued that the decision to determine if the history and/or physical exam is medically appropriate should be based upon clinical judgement and should not have a place in determining the service code.  Further, by removing the history and/or physical exam as an element of determining the coding level, there is nothing distinguishing 99201 from 99202; therefore, CPT 99201 has been deleted.

Starting January 1, 2021, the level of service will be based upon Time or Medical Decision Making (MDM).  The Time will be the Total Time spent with the patient on the actual date of service. Total Time includes face-to-face and non-face-to-face time. The activities must be provided by a physician or qualified health care professional in order for the time to be counted.  This means any activities performed by clinical staff may not be included in calculating Total Time. Prolonged service codes should be used for visits that are 75 minutes or longer for new patients and for services 55 minutes or longer for established patients.

The changes to the MDM tables come in the form of clarification on the definition of the existing three elements of MDM:

  1. DIAGNOSES: The number and complexity of problem(s) that are addressed during the encounter.

The problem must be evaluated or managed to be considered “addressed” which includes consideration of further testing or treatment even if not elected by the patient.

  1. DATA: The amount and/or complexity of data to be reviewed and analyzed. Data is defined as tests, documents, orders or gathering of data from independent historian(s). Each test ordered or reviewed separately may now be counted individually.  For example, multiple labs were counted as one but now they will be counted individually. Providers need to remember to document what was ordered and why it was ordered.  Any interpretations of data should continue to be documented as well. As always, an order a provider writes and interpreted will still be counted just once.
  2. RISK: The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). Risk has not changed but the definition has been expanded to those care management options that are considered by not selected after sharing medical decision making with the patient.

Here is what the decision tables for service leveling will look like on January 1, 2021.

E/M Level Selection Table: New Patients

E/M Code History Exam MDM Time in Minutes
99202  

 

No longer determines level of service. Document based upon medically appropriate clinical judgement.

Straight Forward 15-29
99203 Low 30-44
99204 Moderate 45-59
99205 High 60-74

 

E/M Level Selection Table: Established Patients

E/M Code History Exam MDM Time in Minutes
99211 N/A: Visit level does not require a physician or QHCP
99212 No longer determines level of service. Document based upon medically appropriate, clinical judgement. Straight Forward 10-19
99213 Low 20-29
99214 Moderate 30-39
99215 High 40-54

Preparing now will be the key to success.  Here are some tips to start health centers off:

  1. Run a frequency report by code to see where the health center is performing now. Perhaps looking at last year’s dates – prior to the COVID19 Public Health Emergency – would be most relevant.
  2. Assess the current documentation processes used now to determine E/M visit levels. Health centers can review those levels across the practice and/or by provider.
  3. Review a sample of charts to see how levels may change under time-based documentation or the MDM method.
  4. Identify gaps in documentation that support each method.
  5. If providers are considering Total Time, clock a sample of visits by activity to determine if it’s easy or challenging to capture time elements across various activities of the date of service.
  6. Meet with the EMR/EHR vendor to discuss possible enhancements to documentation tools to capture elements of time on the date of service and/or MDM.
  7. Continue to follow the health center’s MAC and the AMA for changes.
  8. Read and understand the Final Rule when it is released later in 2020.

Reference sources used for this blog:

AMA CPT E/M and Prolonged Services Code and Guideline Changes

Implementing CPT® Evaluation and Management (E/M) revisions | American Medical Association

Calculating the Effect of the 2021 E/M Changes on Primary Care – AAPC Knowledge Center

Finalized Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020 | CMS

Physician Fee Schedule | CMS

E/M Code Categories

AMA “Top Ten Tips to Prepare for E/M office Visit Changes”