Medicare Compliance & Reimbursement

Say farewell to 99201.

Big changes are coming to outpatient evaluation and management (E/M) coding. With the recent publication of the 2019 CPT® Editorial Summary of Panel Action, we have a much clearer idea of what may lie in store for coders in terms of additions, deletions, and revisions.

Here are the biggest changes that may well affect your coding beginning Jan. 1, 2021, along with what experts had to say about them.

99201 Will Go Away

The first big change outlined in the Summary is the deletion of 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 …).

Impact: According to experts, this change shouldn’t be too profound for most coders.

“I honestly don’t know the last time I audited/coded a 99201,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director of compliance audit at CancerTreatment Centers of America. “Its elimination helps to align the descriptors more with the available levels of service. Also, having four levels of new patient services requires the documentation to clearly illustrate complexity of the patient’s case; there’s no middle ground.”

Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington, agrees with Hauptman; the change shouldn’t have too much impact, although it could for some practices that use it out of caution, she says.

“[99201] was always for straightforward decision making, which means it was really for visits when the patient didn’t really need to see the doctor because they would get well on their own. For new patients, this would be pretty rare,” she explains. “There may have been practices using this code because they thought it was ‘safe,’ but really it just didn’t make much sense in terms of the scenario that would be appropriately billed with this code.”

Expect History, Exam Component Removal, and MDM Revisions

The Summary also calls for “removing history and examination as key components for selecting the level of E/M service but adding the requirement that a medically appropriate history and/or examination must be performed in order to report codes 99202-99215.”

This explains why CPT^® is deleting 99201. “Since 99201 and 99202 have the same level of medical decision making [MDM], when you remove the levels of history and exam from the descriptors, the codes become virtually indistinguishable, hence the deletion of 99201,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Additionally, “with the new emphasis on MDM as one of two ways to select office visit codes, a lot of work has gone into better describing and distinguishing levels of MDM for clarity. This extends to revising the titles of the three MDM elements,” Moore notes. Those changes include:

• Revising “Number of Diagnoses or Management Options” to “Number and Complexity of Problems Addressed”

Analysis: “This makes total sense. The physician may only be dealing with one diagnosis, but because of the patient’s comorbid conditions, the physician had to address other issues that may or may not be actual diagnoses,” explains Hauptman.

According to Bucknam, this ruling makes things a lot clearer for coders. “There was always a certain amount of confusion about whether and how to count diagnoses. If a diagnosis was listed but there was no documentation that specifically addressed that diagnosis, could you count it? How much management constituted management? If you just asked how the patient was feeling, did that count?”

“I imagine there will be a lot more information and details when the new codes come out; but in any case, it’s easier to see what the number and complexity of problems address means than the more vague number of diagnoses of management options,” Bucknam says. “It’s clear that just listing a diagnosis is not enough, you get credit for the problems you addressed during this visit.”

• Revising “Amount and/or Complexity of Data to be Reviewed” to “Amount and/or Complexity of Data to be Reviewed and Analyzed”

Analysis: “I think that this change will require some more explanations, but overall I think they will be looking for more information about how the data was used,” says Bucknam. “It won’t be enough to just pull in an X-ray interpretation or lab results; [payers] will want some discussion of the significance or the result and how that information will be used in the treatment of the patient.”

• Revising “Risk of Complications and/or Morbidity or Mortality” to “Risk of Complications and/or Morbidity or Mortality of Patient Management.”

Analysis: The change in titling more appropriately illustrates what the physicians are doing. “They are managing a patient or perhaps a condition the patient has,” explains Hauptman. “This helps to clarify that the whole patient is being managed and not just the one issue in a bubble. Multiple factors go into making patient care decisions and managing the patient; this brings light to the education of the physician and the options available to the healthcare team for the betterment of the patient.”

See How ‘Time’ Will Play a Part

As we already know from the Medicare Physician Fee Schedule (MPFS), beginning on Jan. 1, 2021, the Centers for Medicare and Medicaid Services (CMS) plans to let you choose E/M levels based on the level of MDM your provider engages in during the encounter or the total time of the encounter.

This has led CPT^® to replace the words “typical time” with the words “total time spent on the day of the encounter,” along with changing the times for each of the codes. “The ‘typical time’ currently included in the code descriptors only reflects face-to-face time. But since most office visits have some pre- and post-visit time involved, too, the change to ‘total time’ on the date of the encounter will also include pre- and post-visit time that day,” says Moore.

The Summary does not say what the new times will be, however.

Remember: 2021 is a long way off; stay tuned for any changes that could change again between now and the implementation date.