Oncology & Hematology Coding Alert

You shouldn’t overlook history and exam.

In “Part 1: Nix 99201 From Your New Patient Office E/M Codes in 2021,” featured in Oncology Coding Alert, volume 22, number 3, we examined how new patient E/M codes will change. Next, let’s look at established patient codes. You’ll find that a lot of the changes will be the same.

First, Determine How Established Office Patient Codes Will Change

Currently, for established patient office/outpatient codes (99212-99215), you should use two of the three key components (history, examination, and medical decision making (HEM)) to select the appropriate E/M service level.

But, starting on Jan. 1, 2021, CPT^® will remove history and exam as key components for established patient office codes 99212-99215, just like you will for new patient office codes (99202-99205). Instead, your code selection will be based upon either:

the medical decision making (MDM) level or the total time the physician spent on the encounter on the date of service.

Don’t miss: CPT^® will also update and revise their guidelines, which will further explain how coders should handle MDM and time in 2021.

Note: The new criteria for basing the E/M level on either MDM or time only applies to office/outpatient codes, including established patient codes 99211-99215. The leveling rules for E/M codes in other categories will remain the same.

Warning: Don’t Count Out History and Exam

The history and exam will still be important, and they are still needed elements, says Raemarie 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. They just won’t be counted towards the E/M component.

“When you look at the revised CPT^® code descriptors for [both new and established patient office codes], the code descriptor includes ‘which requires a medically appropriate history and/or examination,’” Jimenez says. “So, they still understand from a clinical perspective, the history and exam play a critical role in understanding what’s going on with the patient. It’s just not going to be bulleted, counting elements. It’s whatever the provider feels is necessary to adequately treat that patient for what the presenting problem is or the reason for that encounter.”

You can find a lot of information in the history and exam that helps support the information for MDM, according to Jimenez. Examples of this include the severity of the condition, which is going to be supplemented by the information found in the history and exam. Also, the status of a condition. Is it a chronic illness? It is stable? Is it exacerbated? Is it not improving? So, in some instances, we are going to be able to glean information from the history and exam.

“As a coder, you are going to be looking at the entire record to get a total picture,” Jimenez says. “I wouldn’t just skip those elements [history and exam] in the medical record and move straight into medical decision making because that information is still important.”

You will want to take the time and familiarize yourself with how to consider the information contributing to the MDM. “These requirements, while much the same, have many differences from how it is done and calculated today. For example, there are still four levels of MDM – straightforward, low, moderate, and high, but CPT^® has revised how to select diagnoses for the encounter, how to count data towards the visit, and expanded on some definitions in the risk table,” says Robin Peterson, CPC, CPMA, Manager of Professional Coding, Pinnacle Integrated Coding Solutions, LLC.

Editor’s Note: You’ll want to watch for Oncology Coding Alert articles in the coming months where we will break down the new MDM mechanics for 2021.

For more details regarding the 2021 E/M requirements from the AMA, check out the CPT^® Evaluation and Management Code Change Guidelines for 2021 here: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

Examine Established Patient’s Time

Starting in 2021, if you use the total time the provider spent with the patient during an encounter to level the service for established codes 99211-99215, then you should know CPT^® will be replacing the words “typical time” with the words “total time spent on the day of the encounter,” along with changing the standard time thresholds for each of the codes.

Tip: 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 allow you to include those times in your code selection.

Here is a chart outlining the current typical established patient office visit times as well as the times you’ll see in 2021:

Don’t miss: You’ll be able to include such factors in your time calculation as ordering medications, tests, or procedures, documenting and time spent personally doing preauthorization work — as well as reviewing test results and records before you see the patient on the same calendar date. The already considered time elements included today are also counted such as, the time of the actual visit, speaking with and coordinating care, counseling the patient and independently interpreting test results.