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Primary Care Coding Alert

E/M Coding:

Get the Answers to These 5 Frequently Asked 2021 Outpatient E/M Time Questions

Published on Mon May 18, 2020

Note changes in total times, prolonged outpatient services.

Last month, we took an in-depth look at the way medical decision making (MDM) will function as one of the two ways you will determine office and outpatient evaluation and management (E/M) levels beginning Jan. 1, 2021.

This month, we take a closer look at the second of those ways: time. Here are the five big changes in the way you will use it in just a few short months.

What Is the Big Change?

Up until now, you have been restricted to using time only “when counseling and/ or coordination of care dominates (more than 50 percent) the encounter” per the current CPT® guidelines.

However, “starting in 2021, physicians will no longer need to establish how much time was devoted to counseling and coordinating on the day of the encounter,” says Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

What Will Count As Time?

At the beginning of next year, “the time values associated with each office/ outpatient E/M code will change from being ‘typical face-to-face time’ to ‘total time spent on the day of the encounter,’” Walaszek points out.

This means physicians and/or other qualified healthcare professionals (QHPs) can count “their face-to-face time when determining E/M levels, providing the time is spent on activities directly related to the patient’s care on the day of the visit,” according to Walaszek.

It also means “you will be able to count non-face-to-face time the provider spends on patient care, including updating a patient’s clinical information in the record, during the day of the visit,” notes Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Per the 2021 CPT® guidelines, the full list of those activities includes:

  • “Preparing to see the patient (eg, review of tests)
  • “Obtaining and/or reviewing separately obtained history
  • “Performing a medically appropriate examination and/or evaluation
  • “Counseling and educating the patient/family/caregiver
  • “Ordering medications, tests, or procedures
  • “Referring and communicating with other health care professionals (not separately reported)
  • “Documenting clinical information in the electronic or other health record
  • “Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • Care coordination (not separately reported).”

Coding caution: “You will not be able to include time clinical staff normally spend doing their activities,” notes Walaszek.

What Are the New Times?

Rather than a single “typical” time, CPT® has assigned each outpatient E/M level its own time range, as the following table illustrates:

What About Prolonged Outpatient E/M Services?

Currently, reporting prolonged services with direct patient contact involves using add-on codes +99354 (Prolonged evaluation and management … requiring direct patient contact beyond the usual service; first hour …) and +99355 (… each additional 30 minutes …) to any outpatient E/M level. These codes can be added to any E/M service that is based on the elements (history, exam, and/or medical decision making) once the typical time for that code has been exceeded, or to the highest level E/Ms when calculated based on time.

Similarly, for outpatient E/M services without direct patient contact, you are currently using a stand-alone code, 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour), with the add-on +99359 (… each additional 30 minutes…).

After Jan. 1, 2021, however, you will no longer use these codes for outpatient E/Ms 99202-99215. Instead, you will use just one new code: 99XXX. Per its descriptor, you will use this code:

  • For prolonged services with or without direct patient contact,
  • Only in addition to codes 99205, 99215 when they have been selected using total time,
  • On the date of primary service, and
  • For each additional 15 minutes of service.

So, a new patient outpatient E/M lasting between 90-104 minutes would be billed by time using 99205x1 and 99XXXx2, while an established patient outpatient E/M lasting 55-69 minutes would be billed by time using 99215x1 and 99XXXx1.

What About Prolonged Clinical Staff Services With Professional Supervision?

Under CPT® 2021 this will not change. You will continue to report +99415 (Prolonged clinical staff service … direct patient contact with physician supervision; first hour …) and +99416 (… each additional 30 minutes …) for any prolonged E/M service, including 99202-99215, “that involves prolonged clinical staff face-to-face time beyond the typical face-to-face time of the E/M service,” and when a “physician or qualified health care professional is present to provide direct supervision of the clinical staff” per CPT® guidelines.

The bottom line? “Beginning next year, to avoid under-or overcoding outpatient E/Ms, you and your provider will have to be meticulous about keeping track of everything,” cautions Falbo.

(For the full list of CPT® outpatient E/M and prolonged services guideline changes, go to www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf).

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