Primary Care Coding Alert

Also: review how to count total time.

Next year’s office/outpatient E/M changes are minimal, but that doesn’t mean they are insignificant. CPT^® has decided to remove the time ranges from both the new and established office/outpatient E/M code descriptors and replace them with a single time that “must be met or exceeded.”

For example, 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …) has a current time range of 15-29 minutes. However, beginning Jan. 1, 2024, the provider must meet or exceed 15 minutes of total service time on the date of the encounter before you can bill this code by time.

For more information about this update that you can take back to your practice, keep reading.

See the Value in Uniformity

The update makes the office/outpatient E/M descriptors “more consistent with the rest of the E/M code sets,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. This is evidenced by codes like 99221 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) or 99234 (Hospital inpatient or observation care, for the evaluation and management of a patient including admission and discharge on the same date, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.), which have time minimums, but not time ranges.

The new 2024 CPT^® code book will feature revisions to all the office/outpatient evaluation and management (E/M) codes. Here is a side-by-side comparison:

Essentially, “this doesn’t really change how the codes are used, but listing the minimum time instead of a range for each code is probably going to be easier to follow,” says Kelly Loya, CPC, CHC, CPhT, CRMA, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services.

Remember: Total time will still include face-to-face time as well as time the physician and/or qualified healthcare professional (QHP) personally spent on the patient’s care on the day of the encounter (i.e., total time on the date of the encounter). But “it does not include time spent in the performance of separately reported services,” explains Jacob Swartzwelder, CPC, CRC, CIC, CEMC, AAPC Approved Instructor, managing director at Compliant Approach Partners, LLC in Las Vegas, NV during his session “E/M Audits for Primary Care” at HEALTHCON Regional 2023 in Washington, DC. Counting the same time toward an E/M service and a separately reported service would be double-dipping.

Note: CPT^® will not be changing the descriptor to 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional), which you may continue to bill for established patients receiving E/M services from a clinical staff person other than a physician or QHP. The code will also continue to require no level of medical decision making (MDM) or total time for you to document.

Stay Tuned for How This Update Could Soon Affect G2212

One possible result of this change may be the resolution to the dispute between CPT^® and the Centers for Medicare and Medicaid Services (CMS) over the reporting of prolonged services and associated threshold times. Basically stated, Medicare created their own code for prolonged outpatient E/M services in 2021, G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure …) to be used instead of +99417 (Prolonged outpatient evaluation and management service(s) time … each 15 minutes of total time …). Both CPT^® and CMS require their codes be used in full 15-minute increments, but you can add +99417 to 99205/99215 once the encounter extends 15 minutes beyond the low end of the current time range for those codes, while CMS requires you to add G2212 when the encounter reaches the high end of the current time ranges for 99205/99215.

Now that the time ranges for 99205/99215 are being replaced by a threshold at the minimum end of the range, it is possible that CMS may follow CPT^® rules and adopt +99417 for prolonged services instead. Stay tuned to Primary Care Coding Alert for more updates.