Gastroenterology Coding Alert

Question: We have heard conflicting reports about whether big changes are coming to E/M payment and documentation in 2020. Can you clarify?

South Carolina Subscriber

Answer: The big changes to E/M services were listed in the 2020 Medicare Physician Fee Schedule proposal, but the changes will not go into effect this year. Instead, the 2020 Final Rule says that the revisions to the E/M guidelines will take place on January 1, 2021.

Several changes, such as the decision to let you use either medical decision-making (MDM) or time to select the level of the outpatient E/M service, the decision to adopt the CPT^® interpretive guidelines for MDM, and the decision to delete E/M code 99201 (Office or other outpatient visit for the evaluation and management of a new patient …) next year will bring Medicare in line with what will be in CPT^® in 2021. CMS decided to abandon its blended payment proposal, which would have seen E/M levels two through four paid for at the same rate, with one rate for new patients and another for established patients.

Prolonged service overhaul: In addition, the way you report prolonged services will change dramatically next year. As of Jan. 1, 2021, you will use CPT^® code 99XXX (Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)) “when time is used for code level selection and the time for a level 5 office/outpatient visit (the floor of the level 5 time range) is exceeded by 15 minutes or more on the date of service,” according to CMS.

One change that will take effect in 2020 is CMS’ decision to introduce principal care management (PCM) beginning Jan. 1.

PCM describes care management services for one serious chronic condition or high-risk disease, which you will be able to document using HCPCS codes G2064 (Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management at least 30 minutes of physician or other qualified health care professional time per calendar month…) and G2065 (Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month…). The codes can be billed by either a primary care practitioner or a specialist overseeing the patient’s care, but only one provider will be able to bill for a specific condition.

Although the prior chronic care management codes require a patient to have two or more chronic conditions, these codes will apply to patients with just one high-risk condition. However, CMS has yet to define what a “high-risk disease” truly is or a list so that practices would really understand when to use this type of code. Keep an eye on Gastroenterology Coding Alert to get the scoop on what this might entail as more guidance is issued.