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General Surgery Coding Alert

CPT® 2021:

Answer 3 Questions to Test Your E/M 2021 Coding Preparedness

Published on Fri Nov 20, 2020

Learn how +99417 fits in.

If you’ve been focused on keeping up with the COVID-19 rules that impact your general surgery practice, you might have let your gaze shift from big CPT® 2021 changes you need to know for E/M visits beginning January 1.

Do this: Turn your attention to the following three questions to see what you know, as well as the associated answers, to see what you still need to learn.

Hint: We’ve laid some groundwork for you in previous General Surgery Coding Alert articles (Vol. 21, Nos. 3, 6, and 9), so this final overview should help you be ready for action next year.

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 surgeons provide?

Caveat: Let’s ignore, for now, code revisions under Care Management Services or Prolonged Services — those are topics for another day.

Answer 1: Just Office or Other Outpatient

“Right now, the most important thing to remember is that the changes apply to outpatient visit codes 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) only,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

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;
  • Base code level on provider’s medical decision making (MDM) (see “Deconstruct Table of Elements to Master MDM in 2021”in General Surgery Coding Alert Vol. 21, No. 9 for a complete discussion) 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.

Add: CPT® 2021 adds new-code +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required 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 of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)). Read more about how to use this code in the answer to question 2.

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

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 ordering diagnostics, coordinating care after the encounter, or even writing documentation — but not time spent by non-billable staff.

Fourth: For extended visits in 2021, you’ll report +99417 in addition to the base code, but only if you meet the following three criteria:

  • Time is the sole basis of your code selection.
  • You’re billing a 99205 or 99215 level code.
  • The time exceeds the minimum time for the primary code by 15 minutes. For instance, a 75-minute new patient visit would warrant 99205 (which describes 60-74 minutes) and +99417 (60+15=75).

“You may report an additional unit of +99417 for each additional full 15 minutes of extra time, but not for any increments less than 15 minutes,” Brame says.

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.

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