General Surgery Coding Alert

Learn new and established office patient code changes.

You and your surgeons will need to shift your focus for documenting and coding E/M office visits in 2021, even though medical necessity remains the overarching criterion for selecting the E/M level.

Here’s why: CPT^® will use a different set of criteria for office visit codes 99202 through 99215 beginning Jan. 1, 2021. Instead of basing the code selection on the level of three key components as you currently do, the new basis for code selection will be primarily “either the level of medical decision making [MDM] performed or the total time spent performing the services on the day of the encounter,” explains 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.

Code changes: CPT^® 2021 will make changes to codes 99202 through 99215 to reflect the shift in the basis of code selection.

For instance: Code 99202 will change from the following 2020 definition:

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

• An expanded problem focused history;
• An expanded problem focused examination;
• Straightforward medical decision making.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family to the following 2021 definition:

Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15–29 minutes of total time is spent on the date of the encounter.

The other codes in the 99202 through 99215 range will have similar changes to their respective descriptors.

Notice: CPT^® 2021 will delete 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…). The code differs from 99202 only in the history and examination components, which aren’t deciding factors in 2021.

See How MDM’s Importance Changes

Rather than serving as one of three key components for selecting a code in the range 99202 through 99215, MDM becomes the central factor in choosing the proper code in 2021, unless you decide to base the code on time (which you’ll read about in the next section.)

You can see from the 99202 code sample above that the definition changes from “which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making” to “which requires a medically appropriate history and/or examination and straightforward medical decision making” in 2021.

Under the 2021 code definitions, MDM is linked to specific codes as follows:

• Straightforward MDM: 99202, 99212
• Low MDM: 99203, 99213
• Moderate MDM: 99204, 99214
• High MDM: 99205, 99215.

Key: History and examination haven’t disappeared from services that the clinician provides. “But the record will need to include a ‘medically appropriate history and/or examination’, rather than defining the level of history and examination as we currently do,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, CA.

Brace for Time Change, Too

If you’re used to using time as a deciding factor for E/M codes only when counseling and/or coordination of care counts for more than 50 percent of total encounter time, get ready to radicalize your focus on time in 2021.

Next year, you may decide whether to base your office E/M coding on MDM or time. In 2021, “You may use time alone to select an appropriate code level for the office or other outpatient E/M service codes whether or not counseling and/ or coordination of care dominate the service,” says Joy.

Other key difference: CPT^® is “changing the definition of the time element associated with codes 99202 through 99215 from typical face-to-face time to total time spent on the day of the encounter, and changing the amount of time associated with each code,” according to Jimenez.

Check out the time parameters CPT^® will use for each E/M code beginning in 2021 (compared to “typical” times listed in 2020 codes):

• 99202: 15-29 minutes (20 minutes)
• 99203: 30-44 minutes (30 minutes)
• 99204: 44-59 minutes (45 minutes)
• 99205: 60-74 minutes (60 minutes)
• 99212: 10-19 minutes (10 minutes)
• 99213: 20-29 minutes (15 minutes)
• 99214: 30-39 minutes (25 minutes)
• 99215: 40-54 minutes (40 minutes).

New code: If you select to report 99205 or 99215 based on time, CPT^® 2021 will also provide a code to report 15 minute increments for extended time beyond 74 or 54 minutes, respectively.

Count these activities in 2021: CPT^® will expand its definition of encounter time in 2021 to include both face-to-face and non-face-to-face services, according to CPT^® Assistant Vol. 30 Issue 2. When you decide to use time to select the code, you’ll tally the total time the physician or qualified healthcare professional spends performing the following activities, according to the article:

• 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 health care 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
• Care coordination (not separately reported).

Time-Based Example

Scenario: A 42-year-old established male patient presents with a painful protrusion in the groin area. The surgeon takes a history, examines the site, has the patient stand and cough. Based on strangulation concern, the surgeon orders an abdominal ultrasound and discusses possible options based on the results. The surgeon documents spending 45 minutes combined face-to-face time and research time related to the history and diagnostic testing.

Coding: This note doesn’t provide enough information on the history and exam to determine an E/M code based on 2020 codes and guidelines.

Because CPT^® 2021 deemphasizes history and exam and allows you to select a code based on MDM or time, you can determine a level for this encounter based on time.

The surgeon spent 45 minutes interacting with this established patient, counseling, and researching his situation, so you could report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40–54 minutes of total time is spent on the date of the encounter) for the encounter in 2021.

Remember: The medical record must reflect the provider’s actions during this 45-minute encounter. “At minimum, the total time spent on the day of encounter should be recorded, and an auditor should be able to review the note and see that the complexity of the problems dealt with would ‘logically’ entail that much time on the encounter date,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a physician and former CPT^® Editorial Panel member in Pasadena, California.