In 2018, Medicare announced its plans for revamping the Evaluation and Management coding structure and was met with a rapid response from the medical community, including the AMA and many other organizations. As a result, the Medicare changes implemented in 2019 were mostly documentation-related changes that generally benefited providers but were not necessarily accepted and implemented by all payers.
In March, the AMA posted the CPT Editorial Summary of Panel Actions for February 2019, which lists specific changes that they intend to make to the E/M codes, effective January 1, 2021. Although the AMA plans to make significant changes to E/M, they in no way are as extreme as the original proposed Medicare E/M changes. Additionally, as the CPT Editorial Committee met earlier this month and will also meet in September, we may see even more E/M changes following the summary from those meetings (May 9-11 and September 26-28).
Medicare has published the 2021 E/M changes they intend to make and now, so has the AMA. We’ve all seen that when Medicare and CPT do not agree on the way in which a specific service, or group of services, should be reported, Medicare may produce HCPCS code(s) with specific guidance for Medicare contracted providers to follow. As any coder is well aware, when a provider is contracted with a payer, they must follow the guidelines and policies specific to the contract they have signed, whether or not it matches with the CPT guidelines.
As coders know, when a provider contracts with a payer, they must follow the guidelines and policies specific to the contract they have signed, whether or not it matches the CPT guidelines. Now that the AMA has published these changes, we will need to wait and see how Medicare responds to them.
E/M codes affected
The new AMA CPT E/M changes are specific only to Office or Other Outpatient Services (99201-99205 and 99211-99215) codes. To date, we don’t have any changes to the inpatient or observation codes. Unless the AMA makes further modifications, these changes will be included in the 2021 CPT codebook, so payers, including Medicare, will need to decide whether or not they will adopt them. They include:
- Deletion of 99201
- New guidelines specific to 99202-99215
- Changes in component scoring for both new and established patient codes (99202-99215)
- Changes to the medical decision-making table
- Changes to the typical times associated with each E/M code (99202-99215)
Deletion of 99201
The AMA is planning to delete 99201 from the E/M code set. That is an official code deletion, meaning it will no longer appear in the codebook after 2020. There are some situations in which you may still need to report 99201, such as those entities that will not immediately adopt the 2021 CPT code changes (e.g., workers compensation payers).
Changes in determining E/M code levels
Although documentation of history and physical examination will still need to be medically appropriate, the amount of history or number of elements examined and documented will not factor into the scoring used to determine the overall E/M level of service. Instead, the basis for code selection will be the level of MDM performed or the total time spent performing the service on the day of the encounter.
To ensure all parties involved understand there is going to be a different set of coding rules for 99201-99215, CPT plans to publish the new guidelines (specific to these codes) under their own section header in the Evaluation and Management section of CPT. Changes will include:
- Guidelines Common to All E/M Services
- Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care and Home E/M Services
- Guidelines for Office or Other Outpatient Services
- Section Overview: Identifying and explaining the new guidelines which are applicable only to the Office or Other Outpatient codes (99202-99205)
- Summary of Guideline Differences: Including a table that identifies the differences between the different sets of guidelines
- Revised existing E/M guidelines: Ensuring there isn’t any conflicting information between the different sets of guidelines
- Definitions and Terms
- Addition of a new Medical Decision-Making Table specific to 99202-99215
- Guidelines for reporting Time when more than one individual performs distinct parts of an E/M service
- Revision of the MDM Table to include Table 2 for Office or Other Outpatient Services-specific scoring information
To this end, the AMA will be changing the definition of the time element associated with codes 99202-99215 from typical face-to-face time to total time spent on the day of the encounter, and changing the amount of time associated with each code. What hasn’t changed is that medical necessity for the level of service must be identifiable within the documentation.
The changes to the titles of the subcategories and time are in the MDM table below.
Medical Decision Making (MDM)
|2019||Number of Diagnoses or Management Options||Amount and/or Complexity of Data to be Reviewed||Risk of Complications and/or Morbidity or Mortality||Typical Time (with a summary of fact-to-face counseling/coordination care)|
|2021||Number and Complexity of Problems Addressed||Amount and/or Complexity of Data to be Reviewed and Analysed||Risk of Complications and/or Morbidity or Mortality of Patient Management||Total Time|
Again, these are the CPT changes; however, any payer contracts (e.g., Medicare or payers that follow Medicare guidelines) may require calculation in another way, so be mindful of those contracts when implementing E/M changes in 2021.
Moving forward it might be a good idea to begin informing providers and staff of the upcoming changes to both CPT and Medicare and then follow closely for additional announcements from both the AMA and Medicare. Or you can simply take the assistance of a medical billing company like MedicalBillersandCoders (MBC) and focus only and only on your patient care. To know more about our medical billing and coding services you can contact us at firstname.lastname@example.org