Neurology & Pain Management Coding Alert

Here’s the 2 elements you’ll need to focus on moving forward.

When a patient presents to your provider for an in-office evaluation and management (E/M) service next year, there are going to be several new moving parts when it comes to coding the claim — along with a few E/M cogs that won’t be getting nearly as much use going forward.

Why? For office visit codes 99202 through 99215, CPT^® will start using different criteria for E/M level selection in 2021. Specifically, “the basis for code selection [will be] either the level of medical decision making [MDM] performed or the total time spent performing the service 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.

As time and MDM rise in the E/M component hierarchy, history and examination will fall. In this issue, we’ll take a quick look at MDM and then focus on how you should apply the time component for 2021.

In future issues, we’ll go further into the MDM changes and other aspects of 2021 E/M coding you’ll need to be aware of to file successful claims.

MDM Elevation Drives Descriptor Changes

Along with time, “understanding medical decision making takes a lead role” in 2021 E/M office visit coding, explain Alicia Scott CPC, CPC-I, CRC, director of education for CCO.us; and Jennifer Sanders, CPC, CPB, CPMA, CPPM, COSC, CPC-I, instructor and subject matter expert at CCO.us.

Scott and Sanders report that the American Medical Association will equate these levels of MDM with these office outpatient E/M visits beginning in 2021:

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

Important: In order to reflect the new concentration on time and MDM as decisive elements, CPT^® will revise all of the preceding codes. For example, 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity …) will become (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making …) in 2021 (altered text for both codes in bold).

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

A Brief History of (E/M) Time

Most coders know the situations in which they’d use time as the deciding factor in selecting an E/M office visit code: When counseling and/or coordination of care counted for at least 50 percent of total encounter time, you could choose your E/M based on time alone.

But these encounters were exceptions, not the rule. In 2020 and in years previous, time was not intended to be the factor in deciding the E/M level, explain Scott and Sanders.

Change coming: Next year, “time alone may be used to select the appropriate code level for the office or other outpatient E/M service codes,” Scott and Sanders say. “Time may be used for leveling whether or not counseling and/ or coordination of care dominate the service. However, when counseling and/ or coordination of care dominates the service, time may only be used for selecting the level.”

So you’ll have to know what counts as E/M encounter time, and what activities coders can count as time when adding to total encounter minutes, Scott and Sanders say.

Remember New Time Parameters; Forget 99201

Next year, you’ll apply these rules about time-based reporting to E/M codes 99202 through 99215 only. These rules do not apply to other E/M codes, such as hospital observation, hospital inpatient, etc.

The rules also don’t apply to 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 …), as CPT^® is deleting the code next year.

Explanation: Codes 99201 and 99202 (… An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making …) both require straightforward MDM; the only differences are the level of history and exam. Since history and exam aren’t deciding factors in E/M codes starting next year, 99201 will be irrelevant and redundant.

Most coders haven’t had much use for 99201 for a while anyway, experts say.

Put Time on Your Side With These Guidelines

Check out the time parameters CPT^® will use for each E/M code in 2021 and beyond:

99202: 15-29 minutes.
99203: 30-44 minutes.
99204: 44-59 minutes.
99205: 60-74 minutes.
99211: Time component removed.
99212: 10-19 minutes.
99213: 20-29 minutes.
99214: 30-39 minutes.
99215: 40-54 minutes.

Count These Activities Toward 2021 E/M Time

CPT^® will expand its definitions of encounter time in 2021 to make them align with the new code selection policy. When code selection is time-dependent, you’ll still tally the total time spent performing the service on the day of the encounter, Jimenez confirms.

The 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.

Scott and Sanders report that you can count these activities toward your time calculation when choosing an E/M level in 2021:

• Reviewing tests/records before seeing the patient.
• Reviewing separately obtained history.
• Performing medically appropriate exam/evaluation.
• Counseling/educating patient/family/caregiver.
• Ordering tests or procedures, providing medications.
• Referring and communicating with other health professionals.
• Documentation of clinical information in the electronic health record (EHR).
• Independently interpreting and communicating results.
• Coordinating care.