EM Coding Alert

If you think many of these changes look familiar, you’re right!

While the E/M section of your CPT^® manual for 2021 will look very different from previous years, the good news is that you already know what it’s going to look like. Those big changes are simply the changes we’ve been telling you about — and preparing you for — all year. Only now, they are finally going to be set in stone.

So, here’s a review of the main changes you’re going to see, which include the planned revisions to the office and outpatient E/M codes, and some tweaks to the chronic care management (CCM) and complex CCM codes that could well affect your E/M coding beginning on Jan. 1, 2021.

99202-99215 Revisions Remain on Track

As expected, CPT^® is proceeding with the five following changes:

Change 1: CPT^® 2021 revises the descriptors and time ranges for 99202-99205 and 99212-99215. In part, the descriptors read “Office or other outpatient visit for the evaluation and management of a new/established patient, which requires a medically appropriate history and/ or examination and … medical decision making ….” This means you may select the level of service based on medical decision making (MDM) alone.

Change 2: CPT^® 2021 keeps the descriptor for 99211 but deletes the five-minute typical time parameter. CPT^® has also changed the typical times for codes 99202-99205 and 99212-99215 to time ranges that represent total time on the date of the encounter, not just face-to-face time with the patient. You may also choose the level of service based on total time for any office/outpatient encounter, not just those where counseling or coordination of care dominate.

As a reminder: Beginning on Jan. 1, 2021, the revised descriptors for 99202-99205 and 99212-99215 reflect total time for “the date of the encounter.” Revised guidelines preceding the E/M codes in CPT^® 2021 also state that the total time on the date of service for 99202-99215 includes the following activities when a physician/other qualified healthcare professional performs them:

• Preparing to see the patient (eg, review of tests);
• Obtaining and/or reviewing separately obtained history;
• Performing a medically appropriate examination and/ or evaluation;
• Counseling and educating the patient/family/caregiver;
• Ordering medications, tests, or procedures;
• Referring and communicating with other healthcare professionals (when not separately reported);
• Documenting clinical information in the electronic or other health record;
• Independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver; and
• Care coordination (not separately reported).

However, “what can be considered toward total time and how providers should document it within the medical record still remains unclear, and practices should reach out to their payers for guidance,” Donna Walaszek, CCS-P, billing manager, credentia ling/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts, advises.

Change 3: CPT^® 2021 deletes 99201.

Change 4: CPT^® 2021 adds +99417 (Prolonged office or other outpatient evaluation and management service(s) …; each 15 minutes …), which will change the way you report prolonged office and outpatient E/Ms. You will use the code when the total time spent on the date of the encounter exceeds 60-74 minutes (the time range for 99205) for new patients or 40-54 minutes (the time range for 99215) for established patients.

Remember: “You will only be able to use +99417 with CPT^® codes 99205/99215 when they are selected based on time and not on medical decision making [MDM]. If the code was selected based on MDM, +99417 may not be reported,” Walaszek notes.

Change 5: CPT^® 2021 revises prolonged service codes +99354 (Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215])) and +99355 (… each additional 30 minutes (List separately in addition to code for prolonged service)).

This means “you will no longer be able to use +99354/+99355 with 99202-99215,” notes Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “However, you will still be able to use the codes with other time-based outpatient E/M services,” Falbo adds.

Revisions Also Affect CCM, Complex CCM

You’ll also have to change the way you report 99490 (Chronic care management services …) next year. CPT^® has changed the time parameters from “at least 20 minutes of clinical staff time … per calendar month,” to the “first 20 minutes of clinical staff time … per calendar month.” You will then report time spent on the service over that 20-minute threshold with a new code, +99439 (… each additional 20 minutes of clinical staff time … per calendar month (List separately in addition to code for primary procedure)).

This change is reflected in another revision to 99487 (Complex chronic care management services …), which has been changed from “60 minutes of clinical staff time … per calendar month” to the “first 60 minutes of clinical staff time … per calendar month. Hopefully, this change “will decrease the challenge of reporting complex chronic care management slightly,” says Falbo.

Additionally, CPT^® has deleted the current language in 99487 calling for the “establishment or substantial revision of a comprehensive care plan.” In the New Year, you’ll have to document that your physician’s comprehensive care plan has been “established, implemented, revised, or monitored,” suggesting that “no longer will you have to document a substantial care plan change in order to bill the code,” Falbo adds.