Our current calendar year has been a difficult and challenging one for all of us in many different ways. The COVID-19 pandemic has impacted our health and well-being, our economy, business operations, availability of supplies, our social customs, and how we receive health services. Perhaps one of the few silver linings is that telehealth became temporarily approved for many services that were intended as face-to-face services only. This has been a critical time for facilitating access to healthcare and for evaluating the effectiveness of our healthcare delivery. Since the most commonly reported professional services are Evaluation and Management (E/M) codes, it seems fitting and timely that the rules for compliance with the documentation of these services should be reevaluated and revised to improve quality of care to patients and to reduce administrative burden.
The criteria established for the appropriate level of service for each encounter has been the focus of billing compliance auditing activities by government and commercial payers. The implementation of macros in the electronic health record (EHR) system has resulted in discrepancies within the electronic documentation for the same date of service. Since the E/M system of quantifying required documentation elements was directly related to the higher levels of service, it was also directly tied to the higher reimbursement and revenue. However, the CMS Medicare Claims Processing Manual, Chapter 12, Section 30.6.1 states:
“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”
Despite this official guidance, there has been consensus among physicians and other licensed healthcare professionals that this E/M scoring system compelled them to spend significant time documenting enough volume in order to meet the appropriate level of service that would capture the valuation of their work and complexity of their patient’s care, whereas a more efficient system of determining proper E/M services could have provided them with more time to provide quality care to patients. The American Medical Association (AMA) has been a direct provider advocate and policy maker for over 175 years and they have responded to the call for a more streamlined, efficient, and effective means of documenting and billing E/M services.
General Changes for 2021
- The Office or Outpatient E/M code selection will rely on:
- Medically appropriate history and/or examination. The History and Examination will no longer be key components of the service and will not influence code selection.
- Medical decision-making (MDM) with new criteria is the only key component for documentation-based code selection.
- Total time of the service will be counted for the entire date of the encounter. The typical time associated with the service code will now be redefined in terms of ranges of minutes.
- The deletion of new patient office or outpatient visit service code 99201. Since both 99201 and 99202 each required a straightforward MDM, it did not warrant keeping both codes with redundancy of the same MDM selection criteria.
- There will be revisions for each of the code descriptions for office and other outpatient E/M service codes 99202-99205 and 99211-99215. You can access and download the new AMA CPT guidelines here: AMA CPT Office-Outpatient & Prolonged Services Guidelines 2021.
- The new code descriptions will no longer state that two or three key components are required to meet the level of service.
- The total minutes associated with each code in range 99202-99205 and 99212-99215 will change. The total time for each code has been described as a range of times for each separate service code. The verbiage will be rewritten as: “When using time for code selection, __ to __ minutes of total time is spent on the date of the encounter.” The time frames differ and are higher for the new patient codes in contrast to the established patient codes.
- The AMA also created a new prolonged service code (992XX) that can be assigned in addition to codes 99215 or 99205 when the service exceeds the maximum range of minutes described in the particular base code. It can only be assigned when 99215 or 99205 is selected based on time (and not MDM). The description will read “Prolonged Services/Prolonged Service With or Without Direct Patient Contact on the Date of an Office or Other Outpatient Service.”
- An important change to the prolonged service codes is that they have been shortened from the 30-minute minimum to 15 minutes. This allows for the significant work documented for the base E/M level to be counted more exclusively towards an appropriate level five E/M service.
- The current system does not permit prolonged codes to be assigned unless at least 15 minutes of service have been performed beyond the typical associated time with the base E/M code. This prolonged service code can be assigned with 99215 after 55 minutes of service time, or with 99205 after 75 minutes of service time.
- Each unit of 15 minutes beyond the base service E/M 99215 or 99205 can be assigned as additional add-on units of the prolonged service code for Office or Other Outpatient Service (992XX).
- This new add-on code (992XX) should not be reported in addition to other prolonged service codes (99354-99355, 99358-99359, 99415-99416).
- Established patient code 99211 will no longer have any typical associated time in the description. The sentence “Typically, 5 minutes are spent performing or supervising these services” will be deleted. However, this service code will continue to be an active CPT code and should continue to be assigned whenever a clinical staff member performs a face-to-face service under the supervision of a qualified healthcare provider.
- The bulleted elements of history and of exam will be removed. Instead, the criteria for each is rewritten as “a medically appropriate history and/or examination,” followed by “and ____ level of medical decision making.”
- The terms “Medically appropriate” now imply that the qualified healthcare professional who reports the E/M services must also determine the nature and the extent of the history and examination for each service.
- The code selection will no longer depend on the level of history or exam. For this reason, the 2021 guidelines will not quantify the elements anymore for assessing the levels.
- The history and exam guidelines for office and outpatient E/M visits also specify that the “care team” may collect information, and the patient (or caregiver) may provide information, such as by portal or questionnaire. The reporting provider must then review that information.
The AMA has proposed significant changes to how the MDM must be scored and CMS has agreed to adopt these changes, eliminating any biased interpretation by the local MACs. These changes will require attention and adjustment to, by our clinicians and our health information professionals: The new E/M descriptions and new MDM table will change how and what QHPs document. This new system will require HIPs to reevaluate how to best educate and train our staff and our healthcare providers to ensure compliance.
The MDM was for nearly thirty years the third of three key components but will now be the only key component that impacts code selection. Look for Part 2 of this article, in which we will explore the new MDM table, in January 2021.
American Medical Association. Evaluation and Management (E/M) Office or other outpatient (99202-99215) and CPT prolonged services (99354, 99355, 99356, 99XXX) code and guideline changes. June 2019. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf.
Centers for Medicare and Medicaid Services (CMS). Evaluation and Management Services Guide. January 2020. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf.
CMS. Medicare Claims Processing manual: Chapter 12 Physicians/nonphysician practitioners, revision 4339; section 30.6. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.
Elizbeth Wilson is corporate compliance and privacy officer at Endeavor Health Services, Inc.