What You Need to Know about New E/M Codes for 2021
Significant changes to the way physicians document and code outpatient evaluation and management services have been made, effective January 1, 2021.
“These are the most significant documentation and coding changes that have occurred in over 20 years,” said Brian Outland, PhD, who provided an overview of these changes.
Physicians billing for Medicare patients will no longer have to use documentation of a patient’s history or physical examination to determine the appropriate level of E/M coding.
“The amount of information documented for the history and physical exam now only is
needed for clinical care of that patient as determined by the physician,” said Dr. Outland, from the Division of Governmental Affairs and Public Policy, Department of Regulatory Affairs, American College of Physicians, Washington, DC. “They will no longer have to use two out of the three elements [history, exam, medical decision-making] to determine the level of E/M for billing.” Now, physicians can choose from either time or medical decision-making to determine code selection.
For billing based on time, the total face-to-face time that is spent on the date of service is used to calculate the time with the patient. Total time includes both the total face‐to‐face and non‐face‐to‐face time spent on the date of the patient encounter by the physicians and other qualified health professionals. “The physician no longer has to have 50% of the face-to-face time spent in counseling and/or coordination of patient care,” he said.
Examples of activities that count toward time, if they are performed on the day of the visit:
- Preparing to see the patient (reviewing tests, etc.)
- 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
- Coordinating care (not separately reported)
Billing for medical decision-making is still based on three domains: number and complexity of problems addressed at the encounter, amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality.
There is no longer a level 1 (code 99201) visit for a new patient, it being rolled into code 99202. Code 99211 is an office or other outpatient visit for the E/M of an established patient that may not require the presence of a physician or other qualified health care professional.
Level 2 (code 99202) is considered straightforward medical decision-making (minimal or one self-limited minor problem, the complexity of data to be reviewed is minimal or none, and the risk of complications to the patient from additional diagnostic testing or treatment is minimal.
For level 3 visits (code 99203), the number and complexity of problems addressed are low, the amount of data to review is limited, and the risk of morbidity from additional diagnostic testing or treatment is low.
For level 4 visits (code 99204), the complexity of medical decision-making is moderate, as is the risk of morbidity from additional diagnostic testing or treatment.
Level 5 visits (code 99205) require a high level of medical decision-making and number and complexity of problems addressed (ie, one or more chronic illnesses with severe exacerbation progression or side effects of treatment or one acute or chronic illness that poses a threat to life or bodily function), an extensive amount and/or complexity of data to be reviewed and analyzed, and a high risk of morbidity from additional testing or treatment.
When billing based on time, physicians can now bill a new prolonged services code (99417); it can be billed with CPT codes 99205 and 99215 when time is used as the primary basis for code selection.
Valuation of the codes have changed. New relative value units in 2021 have increased compared with 2020. In some cases, these increases are up to 30.5% (code 99212) for established patient visits. For new patients, the increases range from 6.5 to 11.3%.
Disclosure
Nothing to disclose