Urology Coding Alert

Know when to bypass the 50 percent counseling/coordination of care requirement/threshold.

As the new year quickly creeps up, it’s your responsibility as an evaluation and management (E/M) coder to be fully integrated with the new guidelines well in advance of their implementation.

You’ve covered all the basics, but now it’s time to take a deeper dive into one of the two methods for reaching an office/outpatient E/M level in 2021 — time. As you see, there are plenty of new guidelines to consider if you want to maximize your physician’s reimbursement while maintaining the same accuracy standards you’re accustomed to.

Read further for a full coding breakdown of what’s new with total time-based coding in 2021.

Know What Services Meet Criteria for Time-Based Coding

When considering total time spent with the patient, you must follow a strict set of criteria that elaborates on what services you can include in that time estimation:

• Preparing to see the patient (e.g. review of tests).
• Obtaining and/or reviewing separately obtained history.
• Performing a medically appropriate history and/or examination.
• Counseling and educating the patient/family/caregiver.
• 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).

Refresher: To start, you want to keep the new rules surrounding documentation of history and examination in mind when evaluating what services may be included in total time estimates. There was plenty of confusion when the Centers for Medicare & Medicaid Services (CMS) initially announced that history and examination would no longer be in consideration as key elements for office/outpatient visits. CMS has since made it clear that history and examination are still a necessary requirement for the documentation process. Rather, the shift in guidelines simply means that you don’t need to include history and examination as equal key components alongside medical decision making (MDM), as you would with the 1995/1997 E/M guidelines.

With this in mind, you should understand how this impacts the process of coding an E/M that’s based on time. “If history and exam are no longer factored into the equation for determining the level of service, then you should include all the time spent in obtaining a patient’s history and performing an examination into the time component,” explains Jaci Johnson Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPC-I, president at Practice Integrity, LLC in San Diego.

To consider: Time has been redefined only as it relates to the new and established office/outpatient E/M categories. “Time for all other categories will maintain the current guidelines,” explains 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. “You need to be especially careful that you’re not blending rules and guidelines from one category into another,” advises Jimenez.

Look Out for Further Instruction on Time Itemization

Piggybacking off the points above, it’s also important to understand that the definition of time as an E/M component has been redefined from the patient-provider face-to-face interaction to the total time spent by the provider on the day of the encounter. The bullet points above detailing what’s included in time elaborate on this — since some of the services included do not involve face-to-face patient interaction.

In fact, there is no existing set of criteria that identifies how a provider should be spending their time during an E/M visit. As the guidelines stand today, there is no indication that time has to be itemized (i.e. documentation that the provider has spent X minutes performing a given task). However, you should keep an eye out for a 2021 Final Rule that expands on this point. “Documentation needs to indicate these services were performed, but it’s unknown as to whether a formal statement will be required with an itemized list of all services performed and their respective time components,” outlines Kipreos.

Compare and Contrast New and Established Patient Time Estimates

Finally, you should consider the difference between the existing office/outpatient E/M timetables and how the total time ranges will differ in 2021. Have a look at the updated total time estimates for new patient office/outpatient visits:

• 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) — 15-29 minutes.
• 99203 (… low level of medical decision making) — 30-44 minutes.
• 99204 (… moderate level of medical decision making) — 45-59 minutes.
• 99205 (… high level of medical decision making) — 60-74 minutes.

Now see how those total time ranges change with respect to established patient office/outpatient visits:

• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making) — 10-19 minutes.
• 99213 (… low level of medical decision making) — 20-29 minutes.
• 99214 (… moderate level of medical decision making) — 30-39 minutes.
• 99215 (… high level of medical decision making) — 40-54 minutes.

Note: With respect to these total time estimates, you should know that the preexisting counseling and/or coordination of care guidelines for time-based E/M coding are not applicable to office/outpatient visits. This means that beginning in 2021, you will not need to reach a 50 percent threshold of counseling and/or coordination of care services in order to report based on time. For new patient and established office/outpatient encounters, you can report total time as the determinant of the E/M level even when counseling and/or coordination of care services are not present.

Get Insights on Prolonged Care Coding

Now that you have knowledge of what services you can and cannot include in the aforementioned total time estimates, the last piece of the puzzle is knowing how to handle a scenario that involves prolonged care. Prolonged care coding for E/M office/outpatient visits that rely on total time estimates will require that you report code 99XXX (Prolonged office or other outpatient evaluation and management service(s)… each 15 minutes) with the respective number of 15-minute interval units.

For example, you’ll code an existing patient with an office visit totaling 71 minutes as 99215 and 99XXX x 2. The 15-minute threshold does not have to be met in order to report 99XXX. Rather, you’ll append one unit of 99XXX for a visit that falls within 55 minutes to 69 minutes, a second unit that falls within 70 minutes to 84 minutes, and so on. For all other non-office/outpatient E/M code sets that may be coded based on the 1995/1997 guidelines and time estimate guidelines, you’ll continue to use the existing prolonged services code range +99354- +99357 (Prolonged Service With Direct Patient Contact).

Note: Code 99XXX will be replaced with a full, permanent code prior to January 1, 2021.