Oncology & Hematology Coding Alert

Remember: You will no longer report code 99201 after Jan. 1, 2021.

During past issues of Oncology Coding Alert this year, you’ve learned all about the updates you will see to new and established patient office/outpatient evaluation and management (E/M) codes 99202-99215 starting on Jan. 1, 2021. Some of these changes include an emphasis on medical decision making (MDM) or time to level the service, as well as the addition of a new prolonged services code.

Review the following tips to make sure you are ready for these upcoming E/M changes in your oncology practice.

Tip 1: Don’t Report 99201 After Jan. 1

Missing from the list of 2021 E/M codes is 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 …). There is a simple reason — once the history and exam components are removed from the E/M level calculation, there is nothing left to distinguish it from 99202 (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…).

The current calculation for 99202 calls for a higher level of history and exam (expanded problem focused) than 99201, which calls for a lower-level problem focused history and exam. MDM for both levels, however, is the same: straightforward. As CPT^® has decided to remove history and exam from levelling calculations, that makes 99201 unnecessary, so CPT^® plans to remove the lowest new patient E/M level from its code set in 2021.

Tip 2: New E/M Guidelines Only Apply to Certain Codes

You will see a change with new and established patient office/outpatient evaluation and management (E/M) codes 99202-99215. Currently, for these codes, you use three key components, history, examination, and medical decision making (HEM) to select the appropriate E/M service level. However, starting on Jan. 1, 2021, CPT^® will remove history and exam as key components for codes 99202-99215. Instead, your code selection will be based upon the MDM level or the total time the physician spent on the patient encounter rendered on that date of service. The remaining E/M code set remains unchanged and continues to require history, examination, and medical decision making to meet the current 1995 or 1997 E/M Documentation Guidelines to appropriately assign the E/M code in those categories.

Tip 3: Physician Should Still Perform History and Exam

Although history and exam will no longer be key components for determining the level of E/M codes 99202-99215, a provider should still perform and document a medically appropriate history and exam.

The history and exam will still be important, and they are still needed elements, emphasizes 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.

Don’t miss: CPT^® 2021 will revise the descriptors for 99202-99205 and 99212-99215 to go along with these new guidelines. In part, the descriptors will read “Office or other outpatient visit for the evaluation and management of a new/ established patient, which requires a medically appropriate history and/ or examination and … medical decision making ….” As you can see, your physician should perform a “medically appropriate history and/or exam.”

Tip 4: Learn How to Report New Prolonged Services Code +99417

In 2021, you will see new prolonged services code +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).

You should report +99417 “to report prolonged total time (ie, combined time with and without direct patient contact) provided by the physician or other qualified health care professional on the date of office or other outpatient services (ie, 99205, 99215),” according to CPT^®. However, you should only report +99417 “when the office or other outpatient service has been selected using time alone as the basis and only after the total time of the highest-level service (ie, 99205 or 99215) has been exceeded.”

Don’t miss: You should not report +99417 for any time unit less than 15 minutes. Also, you should never report +99417 in conjunction with codes 99354, 99355, 99358, 99359, 99415, or 99416.

Tip 5: Expect Definition of “Time” to Change

Starting in 2021, if you use the total time the provider spent on the patient encounter on that date of service to level the service for codes 99202-99215, you should know that 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. 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.

When E/M are assigned by the times documented by the physician, the time recorded and used for leveling must accurately reflect the actual time spent. Physicians, Advanced Practitioner Providers and office staff should be watching for inaccurately recorded time estimates or inappropriately rounding up of time to avoid scrutiny. While many physicians work long hours, keep track and observe when all visits added together, keep watch that the total time claimed doesn’t consistently exceed safe and/or realistic norms. And if it does, immediately investigate and verify the accuracy of recorded visit times.

Don’t miss: You’ll be able to include such factors in your time calculation as ordering medications, tests, or procedures, and time spent personally doing preauthorization work — as well as reviewing records before you see the patient on the same calendar date.