Pediatric Coding Alert

Say hello to new outpatient E/M guidelines, goodbye to 99201.

In Pediatric Coding Alert volume 23 number 1, we gave you some suggestions to help you prepare for the big changes that are going to affect the way you determine office and outpatient evaluation and management (E/M) levels beginning Jan. 1, 2021.

In this, and subsequent articles throughout the year, we’ll be looking more closely at those changes to figure out what they will mean for you in your day-to-day coding. This month, we’ll begin to examine the role medical decision making (MDM) will play in your E/M calculations, and what will happen to the office and outpatient E/M codes as a result.

Exam and History Take a Back Seat

Perhaps the most significant change to E/M services 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) will be that history and exam will no longer make up two of the three components needed to determine levels of new patient visits, or any of the two components needed to determine levels of established patient visits. Instead, only one component, MDM, will be necessary to level visits for both new and established patients.

That does not mean a provider no longer has to document a patient’s history, or that the provider does not need to examine the patient. In fact, “documentation of history and physical examination will still need to be medically appropriate, but the amount of history or number of elements examined and documented will not factor into the scoring used to determine the overall E/M level of service,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

MDM Concept Stays the Same, Guidelines Will Change

In its basic form, “the overall concept of MDM will not change on Jan. 1, 2021,” notes Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

“MDM will still require the provider to establish diagnoses, determine the status of conditions, and determine management options. It will also continue to be defined by two out of these three elements,” Walaszek observes.

Walaszek notes that you will also still identify four levels of MDM — straightforward, low, moderate, and high — which will correspond to 99212 (99202), 99213 (99203), 99214 (99204), and 99215 (99205). And you will still need to meet or exceed two out of the three elements of MDM to qualify for those levels.

But there will be major changes to the guidelines printed in the CPT® codebook that will determine the way you calculate the elements, which will be renamed the “number and complexity of problems addressed,” the “amount and/or complexity of data to be reviewed and analyzed,” and the “risk of complications and/or morbidity or mortality of patient management” beginning in 2021.

More on that in our next issue.

MDM Change Makes 99201 Redundant

One obvious ripple effect of eliminating history and examination as components in determining the level of a particular office or outpatient E/M encounter will be the elimination of 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 …).

That’s because the only key components that currently distinguish 99201 from 99202 are the level of history (problem focused in the case of 99201 as opposed to expanded problem focused in the case of 99202) and the level of exam (again, problem focused in the case of 99201 as opposed to expanded problem focused in the case of 99202).

As those components will no longer be used to determine E/M levels, and as both codes have straightforward MDM as their third component, there is nothing to distinguish one code from the other. So, CPT^® has decided to eliminate the lowest new patient E/M level, and 99201 will be no more next year.

Note These 3 Other Big Takeaways From the MDM Revisions

First, “you should remember that, right now, the changes apply to outpatient visits only,” Falbo reminds coders. Observation or inpatient service codes that rely on the components of history, exam, and MDM to determine levels, for example, have not been affected and will continue in their current form for the foreseeable future.

Second, it is still unclear which payers will be following the ruling and going along with the changes. The fact that CPT® is operating in tandem with Medicare on this issue, however, suggests that there will be a high level of adoption among private payers. Even so, you will be well advised to contact each of your payers to see whether they will be adopting Medicare guidelines for 99202-99215 in 2021.

Finally, regardless of the change in the way you will be calculating E/M levels, one thing will not change: medical necessity will still be key to determining E/M code choice. “Medicare will continue to require that the E/M level must correspond with medical necessity, and you will still have to evaluate such aspects as management intensity and the severity of presenting problem as you choose the code that most accurately describes the level of service your physician has provided to your patient,” says Falbo.

This makes it even more important to use all appropriate diagnosis codes to help demonstrate the complexity of the visit. Not only will this help in the future, but it makes a difference now, with some payers paying based on diagnosis coding.