Decoding Coding: How Does a Procedure Become a CPT Code and Get Assigned a Value? Part 2

As promised last September, I wanted to detail the changes to the CPT Evaluation and Management (E&M) documentation requirements that will be starting January 1, 2021.  Those currently practicing telehealth during this Public Health Emergency (PHE) should already be using the 2021 documentation requirements in determining the correct E&M code to use.  The goal from both CMS (Centers for Medicare and Medicaid Services) and the AMA (American Medical Association) is to reduce the documentation burden.  The clever moniker is “Patients above Paperwork”.  We have all read the 4-5 page patient encounters with outdated elements of the history, 120 ROS questions (119 unrelated to the current encounter) and a comprehensive exam worthy of a queen.  Finally getting to the plan that reads, “22 year old healthy G0 who plans to become sexually active soon, options discussed, IUD. Safe sex information given.”  Surely we can improve.

In 2019, CMS proposed a single code that would combine everything about the 99202-4 and 99212-4 visits.  The AMA disagreed with the grouping set to work to propose another plan.  The AMA-CPT panel came up with simplified documentation requirements approved by CMS and the AMA that preserved more levels of care.  These requirements were vetted through experts in all specialites from allergy & immunology to vascular surgery.  Essentially, all E&M visits will be coded based on the medical decision making only.  The history and physical exam have no documentation requirements and reimbursement will be made on the basis of the Medical Decision Making (MDM) performed and documented.  The provider would then be free to document the elements of the history and physical exam that are relevant to the care of the patient.   In addition, the 99201 code will be eliminated.

Time-based billing codes now have their ranges clearly defined.  In 2021, there will be an add-on code for outpatient care that requires more than 74 (new patient) or 54 (established patient) minutes of time.  In addition, time is not just face to face time, but also includes time spent reviewing tests in preparation for the visit, obtaining and reviewing separately obtained history and ordering medications, tests and procedures. 

The table below summarizes the new rule, including the new work RVU values for 2021.

These changes were not finalized in time for 2020 but will take effect January 1, 2021 for all visits and are currently in effect for all telehealth visits during the PHE.

This link will take you to the chart produced by the AMA to show how to use medical decision making to determine the complexity of the patient.  Essentially, the MDM depends on the number and complexity of the problems addressed, the amount and complexity of the data to review and the risks of complications/morbidity/mortality of the patient’s care.

These changes will allow doctors to focus on caring for the patient, not caring for the computer.  The history change will reduce the cut and paste errors that include information valid days to years earlier but not currently valid.  The physical exam will no longer include elements of the exam that may or may not have been done (my favorite is to ask medical students what PERRLA stands for and how did they test for accommodation) and surely are not relevant to the visit today. 

The MDM will be based solely on the problems, data and treatment from the current visit.  Hopefully, this shift in E&M coding will achieve its intended goal: better care of the patient.

Dr. Hathaway welcomes your questions and comments.  This information is for informational purposes only.  Please consult with your billing specialist before applying this coding information to your practice.