Evaluation & Management Code Changes Set for 2021

Major changes to office and outpatient evaluation and management (E/M) codes will take effect Jan. 1, 2021. These changes will affect only Current Procedural Terminology (CPT) codes 99201–99205 and 99211–99215.

The ACR practice management division will provide E/M training to help rheumatologists and their staffs ensure they’re ready for implementation of the new codes on Jan. 1, 2021.The first training session will take place at the ACR State-of-the-Art Clinical Symposium on Friday, March 27, in New Orleans. For questions or information on training, contact practice@rheumatology.org.

In response to the Centers for Medicare & Medicaid (CMS) proposal to collapse the E/M codes, the American Medical Association CPT Editorial Panel, Relative Value Update Committee and representatives from medical societies worked to overhaul the complete office/outpatient code set. The revised codes have shortened code descriptors, as well as new time elements. For example, the current descriptor for CPT 99214 is:

• “Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity.
• “Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.”

Effective Jan. 1, 2021, the code descriptor will be:

• “Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
• “When using time for code selection, 30–39 minutes of total time is spent on the date of the encounter.”

Through 2020, providers should continue to follow current coding guidelines to use all three E/M key elements (history, examination and medical decision making) to determine the level of a new office/outpatient encounter, and to use two out of the three key elements to determine the level of an established office/outpatient encounter. Starting Jan. 1, 2021, performance of a history and/or exam will still be medically appropriate for reporting all levels of an E/M service, but will no longer play a significant role in the E/M code selection. Instead, providers will select the code based only on the level of medical decision making (MDM) or total time.

Key changes to remember for 2021:

• • Deletion of CPT code 99201: Due to low utilization of the level 1 code for office or other outpatient visit for the evaluation and management of a new patient, CPT code 99201 will be deleted in 2021.
  • History and examination will no longer have a significant role in office/outpatient E/M code selection: Although they are necessary factors to report an E/M visit, starting Jan. 1, 2021, the history and examination elements will no longer be key factors in the office/outpatient E/M code selection.
  • Change in definition of time: The definition of time associated with E/M levels 99202–99215 will be changed from “typical face-to-face time” to “total time spent on the day of the encounter.” Starting in 2021, providers will no longer need to establish how much time was devoted to counseling and coordinating on the day of the encounter. The time values associated with each of the revised office/outpatient E/M codes will reflect the total time spent on the day of the encounter.
  • Revisions to the MDM elements for codes 99202–99215: There will be changes to the wording of the MDM elements:
  • • “Number of Diagnoses or Management Options” will change to “Number and Complexity of Problems Addressed”
    • “Amount and/or Complexity of Data to be Reviewed” will change to “Amount and/or Complexity of Data to be Reviewed and Analyzed”
    • “Risk of Complications and/or Morbidity or Mortality” will change to “Risk of Complications and/or Morbidity or Mortality of Patient Management”

The CMS has also added important changes to billing for prolonged services. The 2020 Physician Fee Schedule final rule contains exclusion for reporting CPT codes 99358 and 99359 (Prolonged Services Without Direct Face-to-Face Patient Contact Services) when using total time as the deciding factor for an E/M office/outpatient service.

These updates will have implications for documenting E/M services and assigning codes, because Medicare and third-party payers may add their own guidelines for claim submission. Rheumatology practices will need to be knowledgeable about each payer’s guidelines and policies to ensure accurate E/M coding for error-free claim submission.