As of January 1, 2021, the American Medical Association and the Centers for Medicare and Medicaid Services implemented changes to evaluation and management services. The changes are meant to decrease the amount of required documentation and increase the amount of time spent with patients. The E&M codes affected are 99201-99215 and all other E&M codes will remain unchanged. Prior to January 1, 2021, reimbursement was based on three components: History, Exam and Medical Decision Making. With the new process, History and Exam will not be used in the determination for reimbursement but will still need to be documented in the patient’s office note(s). Reimbursement determinations will now be based on the amount of time spent with a patient and/or medical decision making.
Using Time – Physicians may now use total time spent (on the date of service) to determine the level of billing. This includes both face-to-face and non-face-to-face time. The following will now count towards the total time spent:
– Preparing for visit with patient (reviewing tests, etc.)
– Obtaining and/or reviewing separately obtained history
– Performing a medically appropriate examination and/or evaluation
– Counseling/Educating the patient/family/caregiver
– Ordering medications, tests, procedures
– Referring to and communicating with other health care professionals (when not separately reported)
– Documenting clinical information
– Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
Using Medical Decision Making – If the provider chooses to use Medical Decision Making to determine the appropriate E&M code, the following must be considered:
– Number or complexity of issues/problems that are addressed during the visit
– Amount or complexity of data to be reviewed & analyzed
– Risk of complications, morbidity and/or mortality of management decisions made at the visit that are associated with the discussed problems, diagnostic procedures and treatments
Brief Overview of Changes
|
Element |
Prior to 2021 | Effective 2021 |
|
Time |
√ (more than 50% required face-to-face) | √ (50% face-to-face no longer required) |
|
Medical Decision Making |
√ |
√ |
| History | √ |
× |
| Exam | √ |
× |
E&M CPT Coding Changes for New Patient Visits
CPT code 99201 has been deleted from the 2021 CPT Code Set. However, the code descriptors for 99202 – 99205 have been revised.
|
CPT Code |
Medical Decision Making |
Total Minutes Spent |
|
99202 |
Straightforward |
15 – 29 |
|
99203 |
Low |
30 – 44 |
|
99204 |
Moderate |
45 – 59 |
|
99205 |
High |
60 – 74 |
**For services that last longer than 74 minutes, a new add-on code has been created. and a new CPT code has been created and added to be used in conjunction with 99205
99417 of G2212 – Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services.)
99417 should be reported with 99205 or 99215 if the codes were selected based on the time alone and not medical decision making. A service of less than 15 minutes should not be reported. For Example:
A physician spends a total of 84 minutes with a patient during an office visit. For the first 40 – 54 minutes, 99215 would be reported. Since the physician spent an additional 30 minutes with the patient beyond the allotted 54 minutes, 2 units of 99417 should be reported. The claim for this encounter would be coded as: 99215, 99417, 99417
Since 99417 is an add-on code, a 25 modifier is not required. More about 99417 can be found here: https://practice.asco.org/sites/default/files/drupalfiles/2020-09/ProlongedServicesUpdate09.21.20.pdf
99358 – Non face-to-face prolonged care for services on a date other than the date of a face-toface encounter. This represents prolonged evalutation and management services before and or after direct patient care; first hour. 99359 for each additional 30 mintues.
E&M CPT Coding Changes for Established Patient Visits – CPT code 99211 is still available for use; however it no longer includes the time reference that it did prior to 2021.
CPT Code Medical Decision Making Total Minutes Spent
|
CPT Code |
Medical Decision Making |
Total Minutes Spent |
|
99212 |
Straightforward |
10 – 19 |
|
99213 |
Low |
20 – 29 |
|
99214 |
Moderate |
30 – 39 |
|
99215 |
High |
40 – 54 |
**For services that last longer than 54 minutes, a new add-on code has been created. and a new CPT code has been created and added to be used in conjunction with 99215
Additional details about the updated E&M codes can be found here: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf or https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx
2021 E&M Reimbursement – For the 2021 coding changes, a review of reimbursements had to be done. To account for changes in RVUs (relative value units), the 2021 conversion factor decreased by $3.68, bringing it to $32.41.
The following is the national average comparing 2020 with 2021. Below is an overview of the new valuations:
CPT Code % Change (from 2020) 2021 Medicare Reimbursement
|
CPT Code |
2020 Medicare Reimbursement | 2021 Medicare Reimbursement |
Change |
|
99201 |
$46.56 | CODE DELETED |
-$46.56 |
|
99202 |
$77.23 | $69.04 |
-$8.20 |
|
99203 |
$109.35 | $106.14 | -$3.22 |
|
99204 |
$167.10 | $159.36 | -$7.73 |
| 99205 | $211.13 | $210.33 |
-$0.47 |
|
99211 |
$23.46 | $22.26 |
-$1.20 |
|
99212 |
$46.20 | $54.20 |
$8.00 |
|
99213 |
$76.15 | $86.78 | $10.63 |
| 99214 | $110.44 | $122.91 |
$12.48 |
| 99215 | $148.33 | $172.27 |
$23.94 |
Additional reimbursement policies can be found here: https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1
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