A New Era of Coding Evaluation & Management Services

After 25 years, the American Medical Association (AMA) Current Procedural Terminology (CPT) office and outpatient evaluation and management (E/M) codes received a major overhaul. These changes, which went into effect Jan. 1, will help reduce administrative burden on providers and roll back some of the rigid requirements for E/M coding by simplifying the code selection criteria, making them more clinically relevant and intuitive.

The code changes will only affect CPT codes 99201–99215. Some of the key changes include:

• Elimination of history and physical examination as elements for code selection
• Allowing providers to choose level of service based on medical decision making (MDM) or time
• Modifications to the MDM criteria
• Deletion of CPT code 99201
• Adding guidelines for split/shared visits
• Changes for billing prolonged service codes

History, Exam Required But Not Scored
The approved revisions to 99202–99215 require that a medically appropriate history and examination be performed; beyond this requirement, the history and exam do not affect coding. Instead, the E/M service level is chosen either by the level of MDM performed or by the total time spent performing the service on the day of the encounter.

Coding tip: According to the Centers for Medicare & Medicaid Services (CMS), medical necessity is still the overarching criterion in selecting a level of service. This means the history and exam still affect the E/M visit even though they are not used in the calculation of the overall level of services.

Deletion of CPT 99201 (new patient, level 1)
Based on billing data, CPT code 99201 is rarely reported by almost all specialties for a level 1 new patient; therefore deleting it will have a relatively minimal impact on practices. CPT code 99211 (established patient, level 1) will remain as a reportable service.

Criteria for Code Selection in 2021
In 2021 and beyond, E/M code selection will be based on either 1) the level of MDM; or 2) the time performing the service on the day of the encounter. For step-by-step guidelines on code selection by MDM or time, click on the links below:

• 2021 Code Selection Based on Medical Decision Making
• Selection of an E/M level Based on Time in 2021

Definition of Time
The definition of time associated with the office and outpatient E/M CPT codes 99202–99215 has been revised from the typical face-to-face time to “total” time spent on the day of the encounter. Total time spent on the day of the encounter now includes non-face-to-face time as well, such as the time a provider spends reviewing diagnostic results after the patient goes home. The total time corresponding to CPT codes 99202–99215 has been defined at specific intervals. For example, to report code 99215, 40–54 minutes of total time must be spent on the date of the encounter.

Activities that Count Toward Time

• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing separately obtained history
• Ordering medications, tests, procedures
• Referring and communicating with other healthcare professionals
• 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

Medical Decision-Making Elements
The medical decision-making elements associated with CPT codes 99202–99215 consist of three components:

1. Number and complexity of problems addressed;
2. Amount and complexity of data to be reviewed and analyzed; and
3. Risk of complications and/or morbidity or mortality of patient management.

To select a level of E/M service, two of the three elements must be met or exceeded. The new medical decision-making Table 2 further outlines the criteria for the E/M code level selection.

Key tip: The MDM for a 99212 is exactly equivalent to the MDM required for a 99202. Similarly, 99213 and 99203 have the same requirements, 99214 and 99204 have the same requirements, and 99215 and 99205 have the same requirements.

Step 1 – Problem: Select the applicable number and complexity of problems addressed at the encounter.

Step 2 – Data: Select the amount and/or complexity of data to be reviewed and analyzed. Each unique test, order or document contributes to the combination of two or combination of three in Category 1.

Step 3 – Risk: Select the risk of complications and/or morbidity or mortality of patient management.

The new guidelines provide updated definitions of the elements of medical decision making. It is important to understand these definitions to ensure selection of the most appropriate E/M level. A full list of the AMA definitions can be found in the “CPT Evaluation and Management (E/M) Office or Other Outpatient Code and Guideline Changes.”

Split/Shared Visits
In circumstances where the physician and a qualified healthcare professional each perform face-to-face and non-face-to-face work for a visit, the time spent by each is summed for the total time. For example, if a physician spends five minutes of time with an established patient and the nurse practitioner/physician assistant spends 25 minutes on the date of the encounter, the total time of the visit would be 30 minutes and CPT code 99214 (30–39 minutes) would be selected per the new time intervals.

New Prolonged Services CPT Code
New prolonged services CPT codes G2212 or 99417 (with or without direct patient contact) were created to describe a prolonged office and outpatient E/M service of 15 minutes beyond the total time of the primary E/M procedure (either CPT code 99205 or 99215). It can only be reported when the E/M service has been selected based on time alone (not medical decision making) and only after the total time of a level 5 service (either 99205 or 99215) has been exceeded.

There is still a lot of vagueness in billing for the prolonged service CPT codes. The CMS assigned a status indicator of invalid to code 99417 and will only accept Healthcare Common Procedure Coding System G2212 when billing for the prolonged services.

Coding tip: Providers cannot report CPT codes 99417 or G2212 in conjunction with other prolonged service codes. It is important to understand the key coding guidelines, including:

• List G2212/99417 separately in addition to codes 99205/99215 for office or outpatient E/M services;
• Use the prolonged codes G2212/99417 only with level 5 services when time is the contributing factor;
• Do not report G2212/99417 in conjunction with existing prolonged service codes 99354/99355 (face-to-face prolonged care) or 99358/99359 (non-face-to-face prolonged care); and
• Do not report G2212/99417 for any time unit less than 15 minutes.

The ACR encourages practices to verify with individual payers on their billing/coding guidelines for these new codes. Keep in mind, the the Department of Health and Human Services Office of Inspector General (OIG) states, “The necessity of prolonged services are considered to be rare and unusual. The Medicare Claims Processing Manual includes requirements that must be met in order to bill for a prolonged E/M service code (Medicare Claims Processing Manual, Pub. 100-04, Ch. 12, §30.6.15.1).”