Sweeping changes took place this year for office and other outpatient evaluation and management coding. Here the author reviews the changes, pertinent documentation and how they may apply to your practice.
Just when you thought you had evaluation and management (E/M) codes all figured out ... 2021 has ushered in significant changes in the way we use office E/M codes.
Effective January 1, 2021, the American Medical Association’s CPT Committee made significant changes in the way providers are to select the appropriate office E/M codes.1 These changes apply only to “office and other outpatient” E/M services (CPT 99212 to 99215, CPT 99202 to 99205). E/M coding remains the same for hospital, skilled nursing facility, nursing home, patient home, etc. when choosing the appropriate E/M level.1
These changes apply to all insurance carriers which utilize the CPT coding system, which for all practical purposes is everyone, private carriers and Medicare alike. Keep in mind when billing services with a date of service of prior to December 31, 2020, the 1995 and/or 1997 E/M criteria still applies.1,2
Prior to this year, one based selection of the proper E/M code upon the history documented, the examination performed and the eventual decision-making made.2 Each of the three categories had various criteria or “bullet points” that one had to meet. How many bullets documented in the chart then determined acuity levels. With an initial visit, all three levels needed to be met but on a follow-up exam, only two of the three levels needed to be met.2
Time was another option when selecting an E/M level of service under the previous system. Doctors had to document the amount of face-to-face time spent with the patient in consultation and care coordination, which then determined the appropriate acuity level to bill.2
Starting in 2021, CPT E/M code selection no longer directly utilizes the elements of history and examination. They still contribute to the time and obvious decision-making but these two factors alone do not determine the final coding selection.2 It is important to note, however that history and examination must still appear in documentation to validate billing selection, for medicolegal reasons and for continuity of patient care.
Decision-making alone is the key now when selecting an E/M code.2 The next twist is with regards to “time,” as that now represents the total physician time spent with the patient (both face-to-face and non-face-to-face) on that date of service.2 More on that later …
Key Components In 2021 E/M Coding
To begin with, CPT code 99201 is completely eliminated.1 The reason is that both CPT 99201 and 99202 required “straightforward” decision making.2 Since decision making is now the key element, these two codes became redundant, hence the deletion of CPT 99201. CPT 99211 is still available for nurse only-type encounters.1
The four levels of decision-making continue to be: straightforward; low; moderate; and high complexity.1 This now adds more consistency between initial and follow-up E/M coding levels.
• Straightforward medical decision-making relates to both CPT 99202 and 99212.
• Low medical decision-making relates to both CPT 99203 and 99213.
• Moderate medical decision-making relates to both CPT 99204 and 99214.
• High medical decision-making relates to both CPT 99205 and 99215.
There are three elements of medical decision-making now:
1. the number and complexity of problems addressed;
2. the amount and or complexity of the data to be reviewed and analyzed; and
3. the risk of complications and/or morbidity and mortality associated with patient management.1
One needs to include two out of three of these elements in documentation for every date of service. This applies to both new and established patients.1 In other words, you only have to document any two combinations of elements (e.g. you can select the number and complexity of problems or the risk of that condition or potential treatments and not necessarily document any data considered.)
Number and complexity of problems. This refers to the number and complexity of the problems addressed at the visit in question.1 The patient may have multiple medical problems, but not all of them may directly impact that day’s evaluation. The intent here is to reduce the “cut-and-paste” and repetitive data seen in some chart notes, which are ultimately irrelevant to the purpose of that particular visit.
Data review. This is a bit tricky and in my observation has not yet been completely worked out. The wording “not separately reported” is important. If you obtain X-rays in your office, you receive payment for the technical component of taking the X-ray and the professional component. Therefore, X-ray interpretation is “separately reported.” You cannot include the X-ray you took as part of the data element review. If you review an X-ray already read by another radiologist, you cannot include that in your data review either, as that was also “separately reported.” The concept here is that insurance companies will only pay for one reading of an X-ray.
If you need to review an outside lab result, diagnostic imaging etc., to determine how you will proceed (such as what surgical approach to use or the need for IV therapy versus oral medications), then these actions apply to your time component and in your risk discussion. Although a bit confusing, anecdotally, better clarification is forthcoming according to various medical directors I have spoken with.
Unique tests are tests which have their own CPT codes.1 So a C-reactive protein (CRP) is one unique test, as is a glucose test if ordered individually. But if you order multiple individual tests which fall under, say a comprehensive metabolic panel or a rheumatoid panel, then the review of the panel is considered a single unique test counting towards your data review.1
What You Should Know About Specific Levels Of E/M Coding
For CPT 99202 and 99212, the number and complexity //of the// problem to be addressed includes:
• one self-limited or minor problem;
• the amount and/or complexity of the data to be reviewed and analyzed is minimal or none; and
• there is minimal risk of morbidity from additional diagnostic testing or treatment.1
For CPT 99203 and 99213, the number and complexity of problems addressed includes:
• two or more self-limiting or minor problems or one stable chronic illness or one acute uncomplicated illness or injury;
• the amount and/or complexity of data to be reviewed and analyzed is limited; and
• there is low risk of morbidity from additional diagnostic testing or treatment.1
One should note that to consider the amount and/or complexity of the data to be reviewed and analyzed ‘limited,’ one must meet the requirements of at least one of these two categories:
• any combination of two elements under tests and documents, including reviewing prior external notes from each unique source, reviewing the results of each unique test or ordering of each unique test; or
• assessment requiring an independent historian.1
For CPT 99204 and 99214, the number and complexity of problems addressed includes:
• one or more chronic illnesses with exacerbation, progression or side effects of treatment or two or more stable, chronic illnesses or one undiagnosed new problem with uncertain prognosis or one acute illness with systemic symptoms or one acute complicated injury;
• the amount and/or complexity of the data to be reviewed is moderate; and
• there is moderate risk of morbidity from additional diagnostic testing or treatment.1
In this case, for the amount and/or complexity of reviewed data to be ‘moderate,’ one must meet the requirements of at least one of three categories, including:
• any combination of three elements under tests, documents, or independent historian, including review of prior external notes from each unique source, review each unique test’s results, ordering of each unique test, or assessment requiring an independent historian;
• independent interpretation of tests; this implies independent interpretation of the test performed by another physician or qualified healthcare professional;
• discussion of management or test interpretation with an external physician or other qualified healthcare professional.1
For CPT 99205 and 99215, the number and complexities of problems addressed is high which includes:
• one or more chronic illnesses with severe exacerbation, progression or side effects of treatment or one acute or chronic illness or injury that poses a threat to life or bodily function.1
For these codes, the amount and/or complexity of data to be reviewed and analyzed is extensive and must meet two of three categories:
• any combination of elements under tests, documents, or independent historian, including review of prior external notes from each unique source, review each unique test’s results, ordering of each unique test, or assessment requiring an independent historian;
• independent interpretation of the test performed by another physician qualified healthcare professional
• discussion of management of test; interpretation with an external physician and or other qualified healthcare professional.1
The risk of complication and/or morbidity or mortality of patient management is high for CPT 99205 and 99215.1
So the next obvious question is what constitutes low, medium or high complexity? What is minimal versus extensive, chronic versus acute? What criteria is the doctor to follow to make these determinations? The answer is that those determinations are left to the discretion of the provider. We examined the patient and we determine the severity of the problem … as it should be. Use your professional judgement. What is the risk of an ingrown nail on a teenager? More than likely, quite low. A patient with a diabetic foot ulcer would clearly be much higher risk. But don’t let the diagnosis alone determine your code level. You still must clearly document your findings in the chart that led you to make the risk level determination.1 These new E/M changes are an opportunity for us to finally bill higher-level CPT codes when appropriate.
In your documentation, you need to state in your note that evaluation of one, two or more chronic/acute condition(s) took place, including review of these specific records and that my eventual decision-making risk is moderate. Remember that the person reviewing your claim is not a same-specialty doctor. Clearly stating conditions, data and decision-making elements, will help assist in an audit.
When One Chooses To Base E/M Coding On Time
The next method to select an E/M code in 2021 is to use total time. This is a change from the previous E/M rules. This now includes total time spent by the doctor (not staff) on the day of the encounter and includes both face-to-face and non-face-to-face time.1
Total time will include:
• Time spent preparing to see the patient, such as reviewing previous tests;
• Obtaining and/or reviewing separately obtained history;
• Performing a medically appropriate examination and evaluation;
• Counseling and educating the patient family or caregiver;
• Time spent ordering medications, tests or procedures;
• Referring and/or communicating with other healthcare professionals;
• Documenting clinical information in electronic or other health record (i.e. writing your chart note!);
• Independently interpreting results (not separately reported); and
• Communicating results to the patient/family/caregiver and overall care coordination (not separately reported).1
As always documentation is the key. You need to document what records you reviewed, who you may have communicated with, etc. The time spent on each element does not need to be documented individually (e.g. 10 min spent in records review, 15 min in examination, etc.). We can simply state that during this encounter I did “xyz” tasks and total time spent was “x” minutes, therefore I am billing code 992XX.
If the patient presented for follow-up of a cellulitis and the total visit was thirty minutes, but you also performed cryotherapy for a wart which took 10 minutes, the total visit time would be twenty minutes for the E/M, with the cryotherapy procedure billed separately.
Be careful in documenting time as there are only eight hours in a work day and it would be unusual to have 10 CPT 99205 codes billed (each requiring spending 60 or more minutes per patient). Also keep in mind that time spent does not include time spent by clinical staff or time spent on separately reportable services such as reading an X-ray (remember this is separately reported) or time spent performing a minor surgical procedure.1
Additional Codes And Modifiers Relevant To Proper Reflection Of E/M Services
The CPT codes listed above have time ranges listed (see table above). But, what about that very complicated patient that requires more clinical time than that listed for CPT 99215 or 99205?
For private payors, one can use CPT 99417, applicable when you spend greater than 75 minutes with a new patient or greater than 55 minutes with an established patient. This code description is in 15-minute blocks. So, when spending 30 additional minutes with the patient, billing would be two units of CPT 99417. You must complete the 15-minute block, so if one spends only 17 additional minutes, that would only count as one unit of CPT 99417.1
For Medicare, HCPCS code G2212 can apply to the same scenario as above with one twist. You must go over the maximum time for CPT 99205/99215 by 15 minutes before you can use this code. So, CPT 99215 requires 40 to 54 minutes spent with the patient, so you cannot start to bill G2212 until 54 minutes plus 15 minutes, or until greater than 69 minutes is spent with the patient. For CPT 99205 you must exceed 75 minutes, plus 15 minutes so you can only bill this code after you spent 89 minutes with the patient. Billing for 89 to 103 minutes would be CPT 99205 and one unit of G2212. If you exceed 103 minutes (104-118 minutes), you would bill 99205 and two units of G2212, etc.1
Also, for highly complex patients, Medicare has another HCPCS code (G2211) which one could append to any level E/M due to a higher complexity of the patient. This is an “add-on” code. Unfortunately, Medicare has delayed implementation of this code until 2024.1
There are no new modifiers with regards to the use of E/M coding. The use of modifier 24/25/57 is unchanged. Insurance carriers scrutinize these modifiers (especially the 25 modifier) carriers so make sure you understand their proper use. The E/M service must be significant and separately identifiable from the procedure being performed on the same encounter. Each procedure has an E/M component built into the fee allowance for that code. So, you must document something above and beyond that in order to be paid for both services. Check the APMA’s online coding resources or insurance company manuals if you need further clarification of the use of these modifiers.
For additional information, I would recommend that you go to the APMA website (www.apma.org) as they have additional up-to-date information, including webinars with vignettes to help decipher 2021 E/M coding. Even though the fee schedule for procedures has decreased, I believe the increase in the E/M reimbursement should offset that loss. We should now be able, when appropriate, to bill for the higher level of E/M code which were almost impossible for us to reach (except for time component billing) in the past.
Dr. Poggio has been on the California Podiatric Medical Association’s Medicare committee and has served on their Carrier Advisory Committee since mid-1996. He has consulted for several national insurance companies and has written many articles and lectured on billing and coding issues for podiatric offices.
1. American Medical Association. CPT evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99417) code and guideline changes. Available at: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf . Revised March 9, 2021. Accessed March 18, 2021.
2. Centers for Medicare and Medicaid Services. Evaluation and management services guide. Medicare Learning Network. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf . Updated February 2021. Accessed March 18, 2021.