Why are these changes necessary?

Changes are meant to simplify code selection criteria, make coding more clinically relevant and to reduce documentation overload for office-based evaluation and management (E/M) services, while continuing to differentiate payment based on complexity of care.

 

Key elements of major revisions for 2021:

 

  • Physicians may choose their documentation based on medical decision making (MDM) or total time (including non-face-to-face services).
  • History and exam are still important parts of the notes and may contribute to both time and MDM, but they will no longer be scored for determining the level of the E/M
  • MDM criteria has moved away from simply adding up tasks to instead focusing on tasks that affect the management of a patient’s
  • Code 99201 was
  • Codes 99202 to 99215 were

 

Changes to time documentation

Time will now be defined as the total time spent by the provider (both face-to-face and time spent on non-face-to-face activities related to this patient’s visit performed on the same day as the visit). This may include the services listed below but should not include time spent on separately billable services (such as X-ray interpretation). Effective January 1, 2021:

  • The total time spent must be documented clearly by the provider for the E/M level to be determined by time and does not include ancillary staff
  • Time will no longer need to be dominated by
  • All time used for leveling the E/M must be on the same day as the face-to-face

 

Services included in total time:

  • Preparing for the visit (for example, reviewing test results)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically necessary examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering tests, medications, prescriptions or procedures after the visit
  • Referring and communicating with other health care professionals (when not reported separately)
  • Documenting clinical information in the patient’s medical record
  • Independently interpreting results (not separately reportable) and communicating results to the patient/family/caregiver
  • Care coordination (not separately reportable)

New patient E/M code

Typical time (2020)

Total time (2021)

99201

10 minutes

Code deleted

99202

20 minutes

15 to 29 minutes

99203

30 minutes

30 to 44 minutes

99204

45 minutes

45 to 59 minutes

99205

60 minutes

60 to 74 minutes


Established patient E/M code

Typical time (2020)

Total time (2021)

99211

5 minutes

Time component removed

99212

10 minutes

10 to 19 minutes

99213

15 minutes

20 to 29 minutes

99214

25 minutes

30 to 39 minutes

99215

40 minutes

40 to 54 minutes


Prolonged office services

2021 changes include addition of a new add-on code (currently labeled 99417) for prolonged office visits when time is used for code level selection, including face-to-face and non-face-to-face provider time of at least 15 additional minutes on the same date of service for level five office visits (99205, 99215).

 

Medical decision making (MDM)

Using the new MDM table, medical decision making for office/outpatient visits will be based on meeting (or exceeding) two out of three categories:


MDM must meet two out of three elements

Code

Level of MDM

Number and complexity of problems addressed

Amount and/or complexity of data to be reviewed and

analyzed

Risk of complications and/or morbidity or mortality of patient management

99211

N/A

N/A

N/A

N/A

99202

99212

Straightforward

Minimal

Minimal or none

Minimal

99203

99213

Low

Low

Limited

Low

99204

99214

Moderate

Moderate

Moderate

Moderate

99205

99215

High

High

Extensive

High


Number and complexity of problems addressed at the encounter:

 

  • Straightforward: One self-limited or minor problem
  • Low: Two or more self-limited or minor problems; one stable chronic illness, one acute, uncomplicated illness or injury
  • Moderate: One or more chronic illnesses with exacerbation, progression or side effects of treatments; two or more stable chronic illnesses; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; one acute complicated injury
  • High: One or more chronic illnesses with severe exacerbation, progression or side effects of treatment; one acute or chronic illness or injury that poses a threat to life or bodily

 

Amount and/or complexity of data to be reviewed and analyzed

The 2021 guidelines list three categories for data:

  1. Tests, documents or independent
  2. Independent interpretation of tests
  3. Discussion of management or test
  • Straightforward: Minimal or none
  • Low (one category required):
    • Two tests/documents or independent historian
  • Moderate (one category required):
    • Three tests, documents and/or independent historian
    • Independent interpretation of a test
    • Discussion of management or test interpretation
  • High (two categories required):
    • Three items between documents and independent historian
    • Independent interpretation of a test
    • Discussion of management or test interpretation

 

Risk of complications and/or morbidity or mortality of patient management

For the purposes of MDM, level of risk is based upon the consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization:

  • Minimal: Rest, gargle, elastic bandages, superficial dressings
  • Low: OTC drugs, physical therapy, minor surgery with no identified risk factors, IV fluids without additives
  • Moderate: Management of a prescription drug, minor surgery with identified risk factors, decision regarding major surgery without identified risk factors, diagnosis or treatment
  • High: Need to discuss higher risk problems that could happen for which physician or other qualified health care professional will watch or

 

Tips to prepare your practice for E/M office visit changes:

 

  • Identify project lead
  • Schedule team preparation time
  • Update practice protocols
  • Consider coding support
  • Review business liability coverage
  • Guard against fraud/abuse
  • Update compliance plan
  • Check with your electronic health record (EHR) vendor
  • Assess financial impact
  • Understand medical liability coverage

 

Resources:

  1. CPT® Professional Edition, 2021. AMA
  2. AMA Elements of Medical Decision Making. https://www.ama-assn.org/system/files/2019-06/cpt-revised- mdm-grid.pdf
  3. AMA Press Release 2021 CPT code https://www.ama-assn.org/press-center/press-releases/ama-releases- 2021-cpt-code-set
  4. Major E/M Changes Coming Soon. Are you prepared? https://www.aapc.com/evaluation-management/em- codes-changes-2021.aspx



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March 2021 Anthem Blue Cross Provider News - California