Oncologists should be prepared for E&M service changes in 2021

It is important for all oncologists to be prepared as significant changes to the Evaluation and Management (E&M) codes E/M are into effect from January 1, 2021.

Components for code selection were narrowed down to make them more clinically intuitive and to reduce variation among contractors and payers.

Elements of MDM affecting coding for an outpatient or office visit include:

  • The number and complexity of problems addressed in the encounter, meaning it will no longer be necessary to document every diagnosis a patient has received—just those being addressed during that visit.
  • The amount or complexity of data to be reviewed and analyzed. This reduces physicians to enter voluminous repetitive test data that is irrelevant or ancillary to the purpose of the visit.
  • Risk of complications or morbidity of patient management. This can now include social determinants of health and reasons behind decisions not to admit a patient or intervene in some way.

Previously, history and exam are two of the three components used to select the appropriate E&M service. In 2021, history and exam will no longer be used to select an E&M service, but still must be performed in order to report CPT codes 99202-99215.

The changes are in the form of the definition of time, changes to medical decision-making criteria, and the addition of a new prolonged services code to current office and outpatient E&M codes (Current Procedural Terminology [CPT] codes 99202-99215).

Definition of time

When it considers the concept of time regarding E&M services CPT codes 99202-99215 are associated with and they have been updated from the typical face-to-face time to total time spent on the day of the encounter.

The total time corresponding to CPT codes 99202-99215 has been defined as specific intervals. For example, in order to report 99215, 40-54 minutes of total time must be spent on the date of the encounter. Currently, 99215 need typically 40 minutes.

Codes selected based on time will include the following activities:

  • Preparing to see the patient
  • Seeing the patient
  • Obtaining and/or reviewing the separately obtained history
  • Ordering medications, tests, and procedures
  • Referring and communicating with other health-care professionals
  • Documenting clinical information
  • Independently interpreting results
  • Communicating results to the patient, family, and/or caregiver
  • Coordinating any other care

After getting informed regarding time definition, let’s look at changes to medical decision-making criteria in detail

Codes 99202-99215 are associated with the medical decision-making elements consist of

  • The number and complexity of problems addressed
  • The amount and/or complexity of data to be reviewed and analyzed
  • Risk of complications and or morbidity or mortality of patient management

Out of the above three; two of the three elements must be met or exceeded to select a level of E&M service.

New prolonged services code

Last, a new code will be introduced to describe a 15-minute prolonged service with or without direct patient contact.

When the E&M service has been selected based on time only (not medical decision making) and only after the total time of a level 5 service (either 99205 or 99215) has been exceeded then It can only be reported.

Additionally, code 99201 (new patient, level 1) will be deleted and it’s rarely reported by oncologists, and therefore its deletion will have a relatively minimal impact on oncology practices. However, reportable service 99211 (established patient, level 1) is still in place.

Do you feel the revised E/M updates will affect your reimbursement? Don’t worry, we are oncology billing and coding experts and we help you to get your claims paid timely and efficiently.