EM Coding Alert

Know which new and established outpatient codes descriptors are changing.

The CPT^® 2024 updates affect some evaluation and management (E/M) codes regularly used in many practices. Dive in now so you’re prepared when the changes go into effect.

The changes include both the new and established office or other outpatient E/M codes 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) and 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …). Read on for the details.

You’ll Want Time On Your Side

The change to the six office/outpatient E/M codes boils down to this: CPT^® removes the time ranges from the code descriptors and replaces them with a single time that “must be met or exceeded.”

For instance, note the underlined (new) portions, and strike-through (deleted) portions of 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10-19 minutes of total time is spent on the date of the encounter minutes must be met or exceeded.)

Why: The changes make the office codes more “consistent with the language of the other timed E/M codes,” explains Melanie Witt, RN, MA, CPC, an independent coding expert based in Guadalupita, New Mexico.

In table form, the changes look like this:

Key: “This doesn’t really change how the codes are used, but listing the minimum time instead of a range for each code is probably going to be easier to follow,” says Kelly Loya, CPC, CHC, CPhT, CRMA, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services.

Look Out for Prolonged Service Resolution

One possible result of the E/M office/outpatient code changes may be the resolution to the dispute between CPT^® and Centers for Medicare & Medicaid Services (CMS) over the prolonged service threshold times.

Remember: CPT^® instruction states that prolonged services begin at the minimum time for 99205/99215, while CMS states that prolonged services begin beyond the maximum time. For that reason, CMS created a distinct code, G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure …) for reporting prolonged services to Medicare.

“CMS sought clarifications on the reporting of evaluation and management (E/M) services, which prompted revisions to the CPT^® 2024 code set, specifically revisions to remove time ranges from office or other outpatient visit codes,” says Robin Peterson, CPC, CPMA, manager of professional coding and compliance services, Pinnacle Enterprise Risk Consulting Services LLC in Centennial, Colorado.

Possibility: Now that the time ranges for 99205/99215 have been replaced by a threshold at the minimum end of the range, it is possible that Medicare may follow CPT^® rules and adopt +99417 (Prolonged outpatient evaluation and management service(s) time … each 15 minutes of total time …) for prolonged services instead of G2212.

Brush Up on Other E/M Nuances

While considering these changes, you should also recall some basic principles about using the office/outpatient E/M codes.

For instance: “Total time will still include face-to-face time as well as time the physician and/or qualified healthcare professional (QHP) personally spent on the patient’s care on the day of the encounter,” explained Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, managing director at Compliant Approach Partners LLC in Las Vegas during his HEALTHCON Regional 2023 presentation. “But it doesn’t include time spent in the performance of separately reported services,” he said.

99211: CPT^® 2024 does not change the descriptor to 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). You should continue to bill 99211 for established patients receiving E/M services from a nurse practitioner (NP), a physician assistant (PA), or any other nonphysician practitioner (NPP). The code will also continue to require no level of medical decision making (MDM) or total time for you to document.

Nursing facility: In addition to 99202-99215 changes, CPT^® 2024 also implements a revision to nursing facility care codes 99306 (Initial nursing facility care, per day, for the evaluation and management of a patient …) and 99307 (Subsequent nursing facility care …), raising their time thresholds by five minutes to 50 and 20 minutes respectively. “It will be important for providers to know these new, higher thresholds if they are seeing patients in a nursing facility,” Loya notes.