Gastroenterology Coding Alert

The new E/M coding guidelines have arrived — make sure you’re on top of them.

Although your office uses outpatient E/M codes nearly every day, it’s not every day that you face major updates to the code set. This year, however, you’re seeing some major changes to the E/M guidelines, which means it’s a good time to ensure you are on top of the latest regulations that surround these codes.

Check out the following three questions, along with the expert answers, to see if you’re ready for the updates.

Question 1: Which Codes are Impacted?

Specifically, which E/M codes are revised, deleted, or added in CPT^® 2021 that will change how you code common services that your physicians provide?

Caveat: Let’s ignore, for now, code revisions under Care Management Services or Prolonged Services — we’ll cover those more in depth in a future issue, since the 2021 Medicare Physician Fee Schedule debuted new Medicare-specific codes for some prolonged services.

Answer 1: Just Office or Other Outpatient

Keep in mind that the E/M changes only apply to the outpatient visit codes 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …).

Key changes: Nine code revisions, one deletion, and one addition embody the coding overhaul, as follows:

Revise: Code descriptors for 99202-99215 change in the following ways:

• Drop levels of history and examination in favor of requiring a “medically appropriate history and/or examination;”
• Delete information about the usual severity of the presenting problem, focusing instead on the complexity of the provider’s work; and
• Base code level on provider’s medical decision making (MDM) or base code selection on time alone.

Delete: CPT^® 2021 deletes 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. … Typically, 10 minutes are spent face-to-face with the patient and/or family), making 99202 the lowest level for new patient office visits.

There’s a simple reason for this change. “When the history and exam components are removed from the E/M level calculation, there is little left to distinguish 99201 from 99202,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, CA. “Both 99201 and 99202 describe straightforward MDM, which is now a primary criterion for code selection,” she adds. The only difference remaining between deleted 99201 and revised 99202 is time, and we’ll discuss that in the next question.

Stays the same: Observation or inpatient service codes that rely on the components of history, exam, and MDM to determine levels have not been affected and will continue in their current form for the foreseeable future.

Question 2: How Does ‘Time’ Change in 2021?

Which of the following items change regarding the time element for each office or other outpatient E/M code in 2021 — how you use time to select a code, the number of minutes in the code definition, what services you can count toward time, or how to report extended visits?

Answer 2: All of the Above

CPT^® 2021 upsets the apple cart for how you’ll use “time” to report office or other outpatient E/M services. Read on to answer the question.

First: You can choose to report the appropriate code 99202-99215 based on MDM or on time alone, whether or not you meet the old requirement that counseling and/or coordination of care dominates the service.

Second: The number of minutes included in the code descriptors changes for each code 99202-99205 and 99212-99215 in 2021. Additionally, prior to January, time was used as a “typical” time. Instead, CPT^® 2021 lists a total time range for each code. For instance, 99212 used to be a “typical” 10 minutes, but now the code identifies the total time range of 10-19 minutes.

Third: “CPT^® is changing the definition of the time element associated with 99202-99205 and 99212-99215 from typical face-to-face time to total time spent on the day of the encounter,” according to Rae Jimenez, CPC, CIC, CPB, CPMA, CPPM, CPC-I, CCS, senior vice president of product at AAPC and coding liaison to the AMA CPT^® Editorial Panel. Total time could include face-to-face time, as well as time spent reviewing the chart before the encounter, time ordering diagnostics, coordinating care after the encounter, or even writing documentation — but not time spent by non-billable staff.

Question 3: Should We Use 95 or 97 Documentation Guidelines?

With all the changes to codes 99202-99215, should we be using CMS’s 1995 or 1997 E/M documentation guidelines to help us ensure that we’ve adequately documented the code level?

Answer 3: Maybe Just CPT^® Guidelines

Along with the code revisions, deletion, and addition for reporting office or other outpatient services in 2021, the AMA has also provided solid and extensive guidance for these codes that should clarify what information you should have in your documentation. And CMS has said that they will follow the AMA guidance — but until official guidance is released, there are no guarantees.

Before turning to the 95 or 97 documentation guidelines, you should carefully read the new guidelines in the CPT^® E/M introduction and text notes throughout the section.

Key: Remember that the guidelines are just that — guidance to help you decide what information needs to be in your documentation. Insofar as the guidance no longer applies, such as how many body systems the history must include for a certain E/M level, you won’t need to turn to the 95 or 97 guidelines.