Starting January 1st, the American Medical Association (AMA) implemented major changes to the 2021 Current Procedural Terminology (CPT) code for outpatient evaluation and management (E/M) services.
The stated reason for the need to change the Evaluation and Management (E/M) guidelines, was that the guidelines do little to support patient care. Simply put, adherence to the old E/M guidelines consume a significant amount of the physician’s time and don’t necessarily reflect the actual work by the physician.
So, in accordance with President Trump’s executive order, directing federal agencies to cut red tape, CMS proposed revisions to the E/M rules to decrease administrative burden and make code level selection more intuitive. CMS feels this will improve payment accuracy and minimize the amount of note bloating from EHR copy and pasting of the same problem list day after day.
The current E/M code set includes guidelines on using the 3 key elements of history, examination and medical decision-making to determine the correct E/M code level to bill.
With that said, starting on January 1st, 2021 practitioners will now document office and outpatient E/M level codes 99202—99215 based on total time on medical decision making (MDM) or the total time on the date of the encounter.
Additionally, because of the new change, it was necessary that the descriptions and guidelines surrounding MDM and time be redefined for better clarity.
Starting with time, except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes 99202 – 99215 whether or not counseling and/or coordination of care dominates the service.
When time is used to select the appropriate level for E/M services codes, time is defined by the service descriptors in each category.
The E/M services for which these guidelines apply require a face-to-face encounter with the physician.
Here are the major points from the 2021 guidelines for Time:
- You will be able to use time alone to select the correct code from 99202-99205 and 99212-99215. Note that 99211 is not in that list because no time is listed in that descriptor.
- The 2021 Time guidelines explain that for 99202-99205 and 99212-99215, total time on the encounter date includes both face-to-face and non-face-to-face time spent by the provider on the same day as the visit.
- When you start counting time for the 2021 codes, you should not include time spent on services you report separately. For instance, if you report care coordination or x-rays using a separate code, you should not include that in the time for the E/M code.
This is because the performance and/or interpretation of diagnostic tests/studies during a patient encounter are bundled together under a separate billing code and not included in determining the levels of E/M services. Even so, it should be documented in your records.
- The total time also will not include time for activities the clinical staff normally perform such as taking vitals.
Physician professional time includes the following activities, when performed:
- Preparing to see the patient (eg, intake forms and studies from other providers)
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering tests or other procedures
- Referring and communicating with other healthcare professionals (when not separately reported)
- Documenting clinical information in the patient’s health record
- Care coordination (not separately reported)
- Typically, because a chiropractor cannot justify the use of the 99205/99215 codes they will not be used.
- If coding using the 99204/99214 codes, make sure that your documentation supports its use.
The following are the time codes used as a determining factor for each category:
New patient codes:
- 99202: 15-29 minutes
- 99203: 30-44 minutes
- 99204: 45-59 minutes
Established patient codes:
- 99212: 10-19 minutes
- 99213: 20-29 minutes
Remember to count only the practitioner time on the calendar day the patient was seen. Do not include time on any other day, and don’t include staff time.
Additionally, It isn’t necessary to note how much time was spent in each activity but the total time for the encounter.
Describe what was done, and document time in a single statement as in the example below.
“I spent 30 minutes reviewing the patient’s intake form, examining the patient, and documenting my diagnosis and findings in the record. I also discussed treatment with the patient, including the possible risk associated with treatment and alternatives to care. The patient stated that they understood the risk and requested that treatment be performed.”
- Though a medically appropriate history and/or examination will not be part of the basis for code selection, history and exam findings that are pertinent to the visit should still be documented.
- Physician documentation must accurately depict what occurred during the encounter, as you still need to be covered in the event of a lawsuit or post-payment audit.
- It’s crucial to understand that your E/M documentation must support the medical necessity of the diagnosis and treatment provided.
- When using time as a coding factor, if a physician reviews medical records or special studies from another source on the day of the encounter, they should document what specific records or studies and their origin.
Also, the physician should sign the document with their full name and credentials (eg, DC) to show that they reviewed them.
- Keep in mind, the AMA does not process or pay claims and as such, they are not the final word on billing policies or payment guidelines. This means that though CMS is accepting the new E/M guidelines for 2021, single payers and commercial Insurance plans may not.
So, it is your responsibility to contact the individual commercial insurance providers and make sure that they are accepting the new guidelines.
Because starting in 2021 practitioners will document office and outpatient E/M level codes 99202—99215 based on time or medical decision making (MDM), part two of this article will review the requirements for medical decision making (MDM) and the different categories associated with each E/M level code.
Knowing this information and the differences should help you in deciding which method would be best for your office.
The “Compliance Made Easy” program is the most complete course on office compliance and includes how to document the correct E/M code.
All the Best,
Dr. John Davenport
Chief Compliance Officer