Otolaryngology Coding Alert

Track the changes from the 2019 Final Rule to the 2020 Final Rule.

With the monumental changes in store for all specialties involving office evaluation and management (E/M) coding, it’s important for you to stay ahead of the curve with plenty of time to spare before 2021 rolls around. We’re here to help you along the way by getting you fully prepared now in the first of a four-part segment covering all the changes in store for next year.

In this issue, you’re going to lay some of the groundwork for the E/M overhaul by answering this true or false questionnaire. These true or false points are especially important given the revisions to the 2021 guidelines featured in the Centers for Medicare & Medicaid Services (CMS) 2020 Final Rule.

Stay ahead of the noise and kick start your transition toward the plethora of 2021 calendar year (CY) changes by tackling these pertinent questions.

See Where the Focus Shifts to Time and MDM, Exclusively

True or False: History, exam, and medical decision making (MDM) will still be required to reach the appropriate E/M code for office/outpatient visits.

False: As per the recommendations of the American Medical Association (AMA), CMS has finalized its plans to make fundamental changes to the E/M coding structure for the 2021 CY. These changes, as outlined by the AMA, begin with the elimination of “history and physical as elements for code selection.” Furthermore, the AMA explains that “while the physician’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.”

Beginning in 2021, CMS will allow for you to code E/M exclusively based on total time or medical decision making (MDM). With respect to MDM, this change means that the MDM level alone can determine the level to which you code a new or established office/outpatient visit.

Furthermore, you’ll also have the option to code to the highest E/M level using time as your only component. While the current guidelines allow for time reporting for E/M services in which counseling and/or coordination of care services consist of more than 50 percent of the visit, the new rules on time reporting will have no such restrictions. Instead, the practitioner will only be required to demonstrate the medical necessity of the visit in addition to documenting the total amount of time they spent with the patient. 

Don’t Write Off the Old Guidelines Just Yet

True or False: The 1995/1997 guidelines will still remain for all E/M codes outside of code range 99202-99215.

True: For new and established office/outpatient visits, CMS will only permit you to code based on MDM or time. However, the 1995/1997 guidelines will still be required for the remaining E/M categories including emergency room (ER), initial and subsequent hospital care, nursing facility, and home visits.

Deletion of 99201 Remains From 2019 Final Rule

True or False: CMS is deleting E/M 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 …) from the CPT^® manual in 2021.

True: The AMA will be deleting E/M code 99201 for the 2021 calendar year. The CPT^® Editorial Panel justifies the deletion of this code by explaining that “CPT^® codes 99201 and 99202 (… An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making …)  are both straightforward MDM and only differentiated by history and exam elements.”

“When you look at the frequency of use in 99201, it’s not reported that often across most specialties,” says 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. “So, the CPT^® Editorial Panel thought the best course of action would be to remove that level of service altogether,” Jimenez explains.

See New Guidelines on Chief Complaint and Hx Documentation

True or False: You will not need to re-enter chief complaint and history that ancillary staff previously documented.

True: For E/M office and outpatient visits that fall within code range 99202-99215, practitioners will not need to re-enter the patient’s chief complaint and history that’s been previously documented by ancillary staff or the beneficiary. The practitioner may instead make a comment that they have reviewed the respective patient information.

See What Prolonged, Complex Services Codes Remain in the Works

True or False: There will be a new add-on code for prolonged E/M services in 2021.

True: Beginning in 2021, CMS will introduce the following prolonged E/M services code:

• 99XXX (Prolonged office or other outpatient evaluation and management service(s) (beyond the total 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 (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services))

In addition to the detailed code description, the AMA explains that this code should “only used 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.”

However, you’ll also want to keep in mind that, in addition to 99XXX, CMS will introduce one more HCPCS add-on G code (GPC1X) that describes “the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care.”

CMS Makes Final Verdict on Blended Payment Rates

True or False: CMS will incorporate a blended payment rate for levels two through four office/outpatient E/M visits.

False: Contrary to some popular belief, CMS concedes in the 2020 Final Rule that the RVS Update Committee (RUC) will make final determinations on relative value unit (RVU) values. This means that there will remain separate payments for each E/M level.