Primary Care Coding Alert

Know what changes, what stays the same, and what we still have yet to learn.

If you read the article “Get Ready for 2021 by Taking These 2 Steps Now” in Primary Care Coding Alert volume 22, number 1, you’ll know that big changes lie ahead in the way you are going to choose office and outpatient evaluation and management (E/M) levels.

In that article, we noted that you’ll begin determining outpatient E/M visit levels based on one of two factors: the total time of service on the date your provider performs the E/M or on medical decision making (MDM) alone beginning Jan. 1, 2021.

This month, we’ll take a closer look at the way MDM will both stay the same and change your E/M levelling calculations in just a few short months. And we’ll also look at how this will change the whole nature of the E/M outpatient codes as a result with our answers to three of your most frequently asked questions.

What Is Going to Stay the Same?

“Right now, the most important thing to remember is that the changes apply to outpatient visit codes 99201-99215 [Office or other outpatient visit for the evaluation and management of a new/established patient …] only,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “Observation or inpatient service codes that rely on the components of history, exam, and MDM to determine levels have not been affected and will continue in their current form for the foreseeable future,” Falbo adds.

Additionally, “the overall concept of MDM will stay the same,” 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 three elements,” Walaszek observes. And once you have established the MDM level, it will still correspond to 99212 (99202), 99213 (99203), 99214 (99204), and 99215 (99205), which will still be linked to straightforward, low, moderate, and high MDM respectively.

Medical necessity still the guiding factor in code choice. One more thing will also stay the same. “Medicare and most other payers will continue to require that the E/M level must correspond with medical necessity,” says Falbo. This means “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,” Falbo cautions.

So, What Is Going to Change?

Missing from that list of E/M levels 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 …) for a very simple reason — once the level of history and exam are removed from the E/M level calculation, there is nothing left to distinguish it from 99202.

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.

The other significant change to the outpatient E/M codes will be in the guidelines that will accompany MDM, which we will examine in the next issue of Primary Care Coding Alert. Those elements, which CPT® and the Centers for Medicare & Medicaid Services (CMS) currently call “number of diagnoses or management options,” “amount and/or complexity of data to be reviewed,” and “risk of significant complications, morbidity, and/or mortality,” will be renamed and revised to account for 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.

What Don’t We Know About the Change?

Currently, one big question about the outpatient E/M changes remains unanswered: Which payers are going to follow these revisions, and which will not? One big clue that may provide the answer lies in the fact that CPT^® and Medicare both seem to be on the same page regarding the changes. That points to a high probability of buy-in among private payers, though it is still too early to tell.

Coding alert: Be prepared! Begin contacting your payers now to see which will be adopting the new guidelines and which will not.