Neurology & Pain Management Coding Alert

Prolonged services coding gets a makeover that could take getting used to.

There’s little time to waste now.

With the new year just a couple of months away, the reality of changes to evaluation and management (E/M) office/outpatient visit coding is settling in. Everyone is going to have to get used to a lot of new rules — and code descriptors — when they report office/outpatient E/Ms in 2021.

But have no fear — we’ve got all the info you need to help make the transition as smooth and seamless as possible. Read on for a breakdown on all the new, revised, and deleted office/outpatient E/M codes for 2021.

Say Goodbye to 99201

You’ve been hearing all year about the massive overhaul in store for E/M office/outpatient services in 2021. However, it’s only when you get a look at the actual code descriptions that this seismic shift within the E/M bedrock becomes a reality.

To start, you’ll want to remind yourself that the last days of code 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 …) are among us. With the deletion of 99201, you’ll encounter a revised code description for the new bottom-level new patient E/M office/outpatient visit code, 99202:

• 99202 (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)

You can see right off the bat that this is not your father’s typical E/M code description. Most apparent is the lack of key elements listed. Since office/outpatient E/M visits in 2021 will focus exclusively on time or medical decision making (MDM), the code descriptions have been revised accordingly. Now, you can see the code description in 99202 includes just the essentials: MDM level and a total time. Furthermore, the history and exam portions of the visit are to be documented as “medically appropriate,” but are not involved in the calculation of your code selection. “Keep in mind that the overriding factor is that the level of care be appropriate for the patient’s presenting problem(s),” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. “Although the history and exam are not included in the level calculation, the medical necessity of the presenting problem(s) are established through the documented “medically appropriate” history and exam,” explains Cobuzzi.

The remaining new patient E/M office/outpatient visit codes following suit with their respective changes to time and MDM:

• 99203 (…low level of medical decision making…30-44 minutes of total time)
• 99204 (…moderate level of medical decision making…45-59 minutes of total time)
• 99205 (…high level of medical decision making…60-74 minutes of total time)

Say Hello to New Descriptors

Before breaking down the code descriptors for the established patient set of E/M office/outpatient codes, take note of what’s fundamentally different about the new code description for 99211:

• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal…)

You can see the code description doesn’t even bother to include an MDM level or total time estimate. Since it’s the default code for any service that doesn’t qualify for at least 10 minutes of total time spent or a straightforward MDM, you’ll opt for 99211. Now, have a look at the remaining respective established patient codes:

• 99212 (…straightforward medical decision making…10-19 minutes of total time)
• 99213 (…low level of medical decision making…20-29 minutes of total time is spent)
• 99214 (…moderate level of medical decision making…30-39 minutes of total time)
• 99215 (…high level of medical decision making…40-54 minutes of total time)

Say What? Prolonged Services Coding Changes Could Confuse

As you process and digest this new set of E/M data, you’ve got one more coding variable to consider: prolonged services. In previous articles, you’ve read about a brand-new prolonged office/outpatient E/M services code that went by the placeholder title of 99XXX. As of 2021, this code will morph into its final form as +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)).

On the surface, this prolonged services code seems rather straightforward. However, there’s two additional revised prolonged services codes you need to consider:

• +99354 (Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or other outpatient services [99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215]))
• +99355 (…each additional 30 minutes (List separately in addition to code for prolonged service))

In contrasting the code descriptions between +99417 and +99354, you can deduce by examining the code description for +99354 that it no longer applies to office/outpatient services within code range 99202-99215. This is a shift from the previous code description, which specifically stated that it was intended for office/outpatient services in addition to other E/M services outlined in the parenthetical notes.

You may report code +99417 only when the encounter is documented to last at least 15 minutes beyond the highest-level new or established E/M office/outpatient visits, 99205 or 99215. The time needed to support +99417 includes time “with or without” direct patient contact. This means that you may include time the provider spends on the patient management that extends beyond the typical face-to-face visit on the date of service.

Coder’s note: “The new guideline for +99417 will state that you should not report the code for any time period less than 15 minutes — meaning you need at least 15 minutes beyond the time allowed for your E/M service,” explains Marie Popkin, CPC, CMCS, BSM, ProFee auditor at HCCS HIM Services in Fort Myers, Florida. This means that you may only report code 99205 for a documented time of 60-74 minutes in 2021. However, once that 75-minute threshold is reached, you may report +99417 for each additional 15-minute interval,” details Popkin.