Urology Coding Alert

Stay ahead of the curve as the new year quickly approaches.

Knowing where to begin planning for massive overhaul of 2021 evaluation and management (E/M) guideline changes is a perpetual struggle among coders. That can be hard enough on its own, but with all the misinformation swirling around the internet, that challenge gets magnified even further.

Today, you’re going to discern fact from fiction by scrutinizing some important details against the CMS 2020 final rule.

Drown out the noise and kickstart your transition into the 2021 calendar year (CY) by tackling these pertinent true/ false questions.

See Where the Focus Shifts to Time and MDM, Exclusively

True or False: History, exam, and medical decision making (MDM) will still be required to reach the appropriate E/M code for office/outpatient visits.

False: As per the recommendations of the American Medical Association (AMA), CMS has finalized its plans to make fundamental changes to the E/M coding structure for the 2021 CY. These changes, as outlined by the AMA, begin with the elimination of “history and physical examination as elements for code selection.” Furthermore, the AMA explains that “while the physician’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.”

Beginning in 2021, CMS will allow you to code E/M exclusively based on total time or MDM. With respect to MDM, this change means that the MDM level alone can determine the level to which you code a new or established office/outpatient visit.

Furthermore, you will also have the option to code to the highest E/M level using time as your only component. While the current guidelines allow for time reporting for E/M services in which counseling and/or coordination of care services consist of more than 50 percent of the visit, the new rules on time reporting will have no such restrictions. Instead, the practitioner will only be required to demonstrate the medical necessity of the visit in addition to documenting the total amount of time they spent with the patient.

Don’t Write Off the Old Guidelines Just Yet

True or False: The 1995/1997 Documentation Guidelines will still remain for all E/M codes outside of code range 99202-99215.

True: For new and established office/outpatient visits, CMS will permit you to code based on MDM or time. “This means that the new guidelines for time and MDM only apply to 99202-99215,” says Jaci Johnson Kipreos CPC, CPMA, CDEO, CEMC, COC, CPC-I, President at Practice Integrity, LLC in San Diego, CA. “For all other E/M codes that do have a time component, you’ll continue to use the existing method,” Kipreos relays.

In the case of the remaining E/M categories including emergency room (ER), initial and subsequent hospital care, nursing facility, and home visits, you’ll adhere to the current 1995/1997 guidelines.

Deletion of 99201 Remains From 2019 Final Rule

True or False: CMS is deleting 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 …) from the CPT^® code book in 2021.

True: The AMA will be deleting E/M code 99201 for the 2021 calendar year. The CPT^® Editorial Panel justifies the deletion of this code by explaining that “CPT^® codes 99201 and 99202 (… An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making …) are both straightforward MDM and only differentiated by history and exam elements.”

“When you look at the frequency of use in 99201, it’s not reported that often across most specialties,” says Rae Jimenez, CPC, CIC, CPB, CPMA, CPPM, CPC-I, CCS, senior vice president of product at AAPC and coding liaison to the AMA CPT^® Editorial Panel. “So, the CPT^® Editorial Panel thought the best course of action would be to remove that level of service altogether,” Jimenez explains.

See New Guidelines on Chief Complaint and Hx Documentation

True or False: You will not need to re-enter chief complaint and history that ancillary staff previously documented.

True: For E/M office and outpatient visits that fall within code range 99202-99215, practitioners will not need to re-enter the patient’s chief complaint and history that’s been previously documented by ancillary staff or the beneficiary. The practitioner may instead make a comment that they have reviewed the respective patient information.

Check Out What Prolonged, Complex Services Codes Remain in the Works

True or False: There will be a new add-on code for prolonged E/M services in 2021.

True: Beginning in 2021, CMS will introduce the following prolonged E/M services code:

• ^{99XXX (Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services))}

Keep in mind: Code 99XXX code is temporary and will be finalized with a completely new and active code in the upcoming CMS final rule.

In addition to the detailed code description, the AMA explains that this code should “only used when the office or other outpatient service has been selected using time alone as the basis and only after the total time of the highest-level service (ie, 99205 or 99215) has been exceeded.”

However, you’ll also want to keep in mind that, in addition to 99XXX, CMS will introduce one more HCPCS Level II add-on G code (GPC1X) that describes “the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care.”

CMS Makes Final Verdict on Blended Payment Rates

True or False: CMS will incorporate a blended payment rate for levels two through four office/outpatient E/M visits.

False: Contrary to some popular belief, CMS concedes in the 2020 final rule that the RVS Update Committee (RUC) will make final determinations on relative value unit (RVU) values. This means that there will remain separate payments for each E/M level with no blended payments to be used.