by Casey Squicquero, Billing Support Group Manager, RevCycle Partners
Rather than using history, examination, medical decision-making and time to determine the level of E/M service, like providers have always used, the update to the E/M coding guidelines will be determined based on 1 of 2 factors:
1. Level of service is defined by medical decision-making for the service
- – Medical decision-making will be based on Straightforward, Low, Moderate or High.
– These levels are outlined in a reference from the AMA: CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.
2. The total time it took to perform the E/M service on the date of the encounter.
– It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff)
– Documentation is still required for audit purposes, and the E/M update only applies to the following E/M codes:
• 99202-99205 New Patient Codes
• 99211-99215 Established Patient Codes
• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals (when not separately reported)
• 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)
New Patient Codes
• CPT code 99201 has been deleted for 2021 and replaced by CPT code 99202.
• 99202 is used when 15-29 mins of total time is spent on the date of the encounter
• 99203 is used when 30-44 mins of total time is spent on the date of the encounter
• 99204 is used when 45-59 mins of total time is spent on the date of the encounter
• 99205 is used when 60-74 mins of total time is spent on the date of the encounter
Established Patient Codes
• CPT code 99211 would never be reported when a physician is present.
• 99212, is used when 10-19 mins of total time is spent on the date of the encounter
• 99213, is used when 20-29 mins of total time is spent on the date of the encounter
• 99214, is used when 30-39 mins of total time is spent on the date of the encounter
• 99215, is used when 40-54 mins of total time is spent on the date of the encounter
• Use +99XXX (Prolonged Service when the E/M service goes beyond the 54 mins with 99215 or the 74 mins with 99205.)
• CPT code +99XXX should be reported in 15 minutes. Use 99XXX in conjunction with 99205, 99215. Additional information on prolonged services is also outlined by the AMA, on the last page, in the following link: Total Duration of New Patient Office or Other Outpatient Services.
How to Prepare for 2021 Changes
• Have your staff sign up for any additional training that may be available either through CMS, Medicare, the AMA or any associations that your office is a member of.
• Reach out to your Practice Management Software to ensure codes are added and confirm documentation requirements are being met.
• Verify with your other vendors, such as your clearinghouse, to ensure the new codes will be accepted come January 1st, 2021.
• Ensure your staff stays up to date on changes and implementation as it comes.
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