Primary Care Coding Alert

This year’s biggest stories reveal what might be in store for the New Year.

As if dealing with the COVID-19 public health emergency (PHE) wasn’t enough, as a coder, you’ve had lots of changes to handle this year, including preparing for the big change to the office or outpatient evaluation and management (E/M) codes that will take effect on Jan. 1, 2021.

You’ve had a lot of questions about these, and other, topics this year. So, we took a look at 2020’s biggest coding stories to try and find some answers about what lies ahead in 2021.

Question: Will the Healthcare Changes Initiated by the 2020 PHE Carry Over Into 2021?

Answer: Most of those changes affected telehealth. They began in March, when the Centers for Medicare & Medicaid Services (CMS):

• Added numerous services to the telehealth list, including 99217 (Observation care discharge day management …), 99218-99220/99224-99226 (Initial/ Subsequent observation care …), 99324-99337 (Domiciliary or rest home visit …), and 99341-99350 (Home visit for the evaluation and management of a new/established patient …);
• Announced that Medicare would begin paying for telephone services such as 99441-99443 (Telephone evaluation and management service …);
• Lifted geographic and originating site restrictions on telehealth and made the services available to “patients located anywhere in the country, including in a patient’s place of residence”; and
• Changed the definition of “interactive telecommunications system” to include mobile phones.

Additionally, the Health and Human Services (HHS) Office of Civil Rights waived HIPPA requirements to allow “everyday communications technologies, such as FaceTime or Skype … during the PHE” for codes on the Medicare Telehealth Code list.

What this means for 2021: HHS renewed the PHE effective October 23, so all the current PHE waivers and regulations will continue until at least January 2021. In all likelihood, HHS will renew the PHE for a good portion of 2021, so you should keep your eyes on the HHS PHE website at: www.phe.gov/emergency/news/healthactions/Pages/default.aspx for information about further PHE extensions.

However, whether these changes will become permanent or go back to their pre-PHE states once the PHE ends is unknown. So, you should also take note of the 2021 Medicare Physician Fee Schedule (PFS) final rule to see if any changes will become permanent regardless of the PHE. The final rule is scheduled to be released on or about December 1, 2020. And you’ll also want to monitor the CMS telehealth list at: www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes periodically to see if any services get added or deleted.

Question: Is There Anything Else I Should Know About the Office and Outpatient E/M Code Changes?

Answer: By now, you should be very aware that, beginning Jan. 1, 2021, you’ll have the option to report office or outpatient evaluation and management (E/M) codes 99202-99205/99212-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) based on total physician/other qualified healthcare professional time on the same date of service (which could include test result reviews, counseling patients or patients’ families, documenting in the medical record, or consulting with other healthcare professionals) or the level of medical decision making (MDM), per the new guidelines found at: www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. You should also be aware that new patient code 99201 will be deleted on that date.

But you may not be aware of the potential problems posed by new code +99417 (Prolonged office or other outpatient evaluation and management service(s) …; each 15 minutes …). Per CPT^® guidelines, you can report +99417 when the total time exceeds the minimum time of 99205 (…. 60-74 minutes…) or 99215 (… 40-54 minutes…) by 15 minutes. For example, per CPT^®, you may report a unit of +99417 when the total time spent on the date of service in conjunction with a 99205 reaches 75 minutes.

However, in the 2021 PFS proposed rule, “CMS’ instructions are not the same as the CPT^® instructions. CMS is proposing to permit +99417 only when the maximum times of 99205 or 99215 have been exceeded by 15 minutes, or when the times for the codes hit 89 minutes or 69 minutes, respectively,” explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

To see if this discrepancy gets resolved, once again you will have to monitor the 2021 PFS final rule.

And remember: “Right now, the changes apply to office and outpatient visits only,” notes Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. All the other E/M services you report will stay the same in 2021.

Additionally, even though “the amount of history or number of elements examined will not determine the overall E/M level of service, a history and physical examination will still need to be performed if medically appropriate — and documented,” Falbo adds.

Question: What’s Going on With ICD-11?

Answer: While ICD-10 revisions continued in 2020 with the addition of a new chapter, Chapter 22 Codes for special purposes (U00-U85), and new codes U07.0 (Vaping-related disorder) and U07.1 (COVID-19), the timetable for the transition to ICD-11 in the U. S. still remains unclear, even though the World Health Organization (WHO) approved the code set in May 2019 for implementation in January 2022.

In fact, AAPC believes it won’t be until 2025 that you will be using ICD-11 for reporting morbidity, and that the clinical modification (CM) version won’t appear until 2027 if needed. So, all you can do to prepare in 2021 is glance at the National Committee on Vital and Health Statistics (NCVHS) website (ncvhs.hhs.gov/) occasionally to see if these predictions continue to hold true.