In 2019, the CPT Editorial Panel approved changes that will significantly impact office and outpatient evaluation and management (E/M) codes. These changes will only affect CPT codes 99202-99215 and will go into effect January 1, 2021.
What changes am I going to see?
Beginning in 2021, the history and examination will be removed as key components for selecting the level of E/M service. A requirement has been added that a medically appropriate history and/or examination must be performed. In addition, the basis for code selection will be either the level of medical decision making (MDM) performed OR
the total time spent performing the service on the day of the encounter.
Why were these changes implemented?
The goal of the E/M changes is to decrease the administrative burden of documentation and coding, decrease the need for audits, and to decrease unnecessary documentation in the medical record that is not needed for patient care.
How do I select the correct code after these changes have been implemented?
First, a medically appropriate
history and/or examination should be documented. Next, choose your reporting pathway, either MDM or the total time on the date of the encounter.
If I choose MDM how do I select which code to use?
There are three elements of MDM:
- Number and complexity of problems addressed;
- Amount and/or complexity of date to be reviewed and analyzed; and
- Risk of complications and/or morbidity or mortality of patient management.
The level of MDM is based on 2 out of 3 of these elements being leveled at: straightforward (minimal), low (limited), moderate, or high (extensive). A table detailing the levels of MDM can be found here: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
If I choose total time how do I select which code to use?
CPT Codes 99202-99215 are broken into 15 minute increasing increments or levels. For example, the new patient E/M codes are divided like this:
- 99202: 15-29 minutes
- 99203: 30-44 minutes
- 99204: 45-59 minutes
- 99205: 60-74 minutes
The established patient E/M codes 99212-99215 are broken into minutes in the same way. In order to bill for an E/M using time, you simply select the level of code that corresponds with the total time spent performing the E/M.
What does “total time” mean?
Total time 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 (it 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). Physician/other qualified health care professional time includes the following activities, when performed:
- 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).
The AMA has released educational tools and summaries of the E/M office visit revisions here: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
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