Updated: Dec 30, 2020
Changes are coming for Evaluation & Management codes beginning January 1, 2021. These changes will specifically affect coding for office and outpatient visits (99201-99215), making them extremely important for Chiropractic offices to review.
The revised coding guidelines for outpatient E/M services represent the first major overhaul of E/M reporting in more than 25 years. The coding guidelines are simpler and more flexible and were developed by the AMA and the Centers for Medicare and Medicaid services in a combined effort to “decrease the administrative burden of documentation and coding“, thus relieving doctors of some clinically irrelevant, time-wasting administrative burdens.
Here is an outline and a summary of the upcoming E/M Coding and Documentation changes. Stay tuned over the coming weeks for detailed posts offering more specific guidance on how to optimize the use of your DocPlus system in accordance with the new guidelines.
New E&M Coding Rules for 2021
New Patient, Level 1 code (99201) will be eliminated completely, reducing the number of levels for new patient E&M services to four.
For established patients, the standard five coding levels will remain.
History and physical examination will no longer be determining factors for selecting the appropriate level of care. (This does NOT mean you are no longer required to document these components. Clinically relevant history and exams must still be documented.)
Medical Decision Making (MDM) or Time will be used to determine the appropriate level of E&M.
AMA’s 2021 Guidelines for Office/Outpatient E/M Codes: New Patient
Let us take a closer look at the coming changes, starting with the new patient codes and descriptors.
99201: This code has been eliminated from the 2021 CPT code set.
99202-99205: In 2021, new patient codes 99202-99205 will no longer require the 3 key components or reference typical face-to-face time. Instead, each of the services includes a “medically appropriate history and examination,” and code selection will be based on the level of MDM or total time spent on the date of the encounter.
Below, you can see the differences between the old code descriptor and the new code descriptor for 99203.
OLD 99203 - Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
NEW 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.
The descriptors for 2021 codes 99202-99205 follow the same structure as the 99203 example above.
The following table shows the requirements for the NEW PATIENT E/M codes in 2021.**
For services longer than 74 minutes, the AMA has developed a new prolonged services add-on code, 99417.
AMA’s 2021 Guidelines for Office/Outpatient E/M Codes: Established Patient
The office and other outpatient E/M codes for established patients will change in line with the revisions to the new patient codes in 2021.
99211: Established patient Level 1 E/M code 99211 will still be available, but its code descriptor will not include a time reference in 2021 (See description below):
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. (No time reference)
99212-99215: Established patient E/M codes 99212-99215 will look a lot like the new patient codes in 2021. (The revised descriptor for 99213 is used as an example below):
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.
*Note the difference in time required between the new patient and established patient codes.
The following table shows the requirements for the ESTABLISHED PATIENT E/M codes in 2021.
You will be able to use the new prolonged services code 99417 as an add-on code with 99215.
Selecting a Level of Office or Other Outpatient E/M Service
The changes coming in 2021 will focus exclusively on TIME and MEDICAL DECISION MAKING (MDM) factors, which means you will select the appropriate level of E/M services based on the following:
The level of the medical decision making as defined for each service; or
The total time for E/M services performed on the date of the encounter.
Medical Decision Making
There are FOUR different levels of Medical decision making for E/M coding, each represented by a certain code or codes. (The concept of the level of medical decision making does not apply to code 99211):
Straightforward (codes 99202 & 99212)
Low (codes 99203 & 99213)
Moderate (99204 & 99214)
High (99205 & 99215 – Not frequently used in Chiropractic offices)
Medical Decision Making (MDM) must also consider the following three elements regarding the patient:
Number and complexity of problems being addressed.
The amount and/or complexity of data to be reviewed and analyzed.
Risk of complications and morbidity or mortality of patient management.
View Full Table Here: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
The Time section of the 2021 E/M guidelines will include important information about the proper use of the revised office and other outpatient codes. Here are the major points from the 2021 guidelines for Time:
You will be able to use TIME alone to select the correct code from 99202-99205 and 99212-99215. Note that 99211 is not in that list because no time is listed in that descriptor.
Counseling and/or coordination of care will not need to dominate an office or other outpatient E/M service for you to code the service based on time in 2021. But for other E/M services that are coded based on time, you will still need to meet the threshold of counseling and/or coordination of care making up more than 50% of the visit.
You will use 99211 if clinical staff members perform the face-to-face visit under the supervision of the physician or other qualified healthcare professional.
A shared or split visit is when a physician and one or more other qualified healthcare professionals perform the face-to-face and non-face-to-face work for the E/M visit. When you’re coding these visits based on time, sum the time spent by the physician and other qualified healthcare professionals to get a total time. Any time that the providers spend together to meet with or discuss the patient should be counted only once (like you’re counting the time of one individual).
A key shift for the office and other outpatient E/M codes is that the time referenced in the 2021 code descriptors is total time. The 2020 descriptors for these codes use intra-service time.
When you start counting time for the 2021 codes, you should not include time spent on services you report separately. For instance, if you report care coordination using a separate CPT® code, you should not include that in the time for the E/M code.
The total time also will not include time for activities the clinical staff normally performs.
New Prolonged Services Code
NEW CODE · 99417 - Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes
Code 99417 is only used when the office or other outpatient service has been selected using time alone as the basis and only after the total time of the highest-level service (ie, 99205 or 99215) has been exceeded.
To report a unit of 99417, 15 minutes of additional time must have been attained.
Do not report 99417 for any additional time increment of fewer than 15 minutes. Prolonged services of fewer than 15 minutes total time on the date of the office or other outpatient service (ie, 99205, 99215) are not reported.
Use code 99417 one time for each 15-minute increment in excess of 54 minutes (99205) for NEW patients and in excess of 74 minutes (99215) for ESTABLISHED patients.
Do not report 99417 in conjunction with 99354, 99355, 99358, 99359, 99415, 99416
Download Full AMA Code and Guideline Changes Here: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
Once again, stay tuned over the coming weeks for detailed posts offering more specific guidance on how to optimize the use of your DocPlus system in accordance with the new guidelines. Please contact our training department with any questions, comments, or concerns you may have at 800-642-0600.