06 Nov 2021 E&M Code Changes Guide
Effective January 1, 2021 CMS is aligning E/M coding with changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office-based, or outpatient, E/M visits.
2020 has given us all plenty to think about so, to simplify this update for healthcare organizations and providers, the Medusind RCM Team has compiled this 2021 E&M Code Changes Guide to enable your practice to plan for and act on these updates in the new year.
The proposed changes are designed to revise the time designations and medical decision making process for all of the E&M codes. Plus, the changes require the performance of an HPI and physical exam only when medically appropriate.
Why E&M Codes are Changing in 2021
For providers in office-based settings across the country the change to E&M Codes in 2021 may feel like a burden. However, the changes are actually meant to decrease the administrative burden on practices of documenting and coding by:
- Decreasing the need for audits, through the addition and expansion of key definitions and guidelines.
- Decreasing unnecessary documentation in the medical record that is not needed for patient care
- Ensuring that payment for E/M codes is resource-based and that there is no direct goal for payment redistribution between specialties.
Key Highlights of the 2021 E&M Coding Changes
- Deletion of code 99201 – Office or other outpatient visit for the evaluation and management of a new patient.
- Elimination of history and physical as elements for code selection. However, it should be medically appropriate for the visit.
- Allowing physicians to choose the E/M level based on medical decision making (MDM) or total time.
- A MDM table that assists in selecting the level of Medical decision making, it consists of 3 elements which are
- Number and complexity of problems addressed
- Amount and/or complexity of data reviewed and analyzed
- Risk of complications and/or morbidity or mortality of patient management
- To qualify for a particular level of medical decision making, two of the three elements for that level of medical decision making must be met or exceeded.
- Time may be used to select a level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service.
- Total time on the date of the encounter.
- It 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.
- Prolonged Services Code
- For prolonged total time in the Office or Other Outpatient Services, use 99XXX.
- Code 99XXX is only used when the office or other outpatient service has been selected using time alone as the basis and only after the total time of the highest-level service (ie, 99205 or 99215) has been exceeded. To report a unit of 99XXX, 15 minutes of additional time must have been attained.
- Code GPC1X to provide payment for visit complexity E/M visits.
How to Prepare for the 2021 Proposed Changes to Evaluation and Management (E/M) Coding
The easiest way to prepare for the proposed changes to 2021 E/M coding is to outsource your medical billing to the nations leading technology enabled RCM provider, Medusind! Our customer’s revenue cycles and medical billing won’t skip a beat because our staff has prepared for this change for months.
If you’d prefer to take it on yourself we recommend a 3 pronged approach:
1.) Simulated Coding to 2021 Rules
Practice makes perfect. To be sure your billing staff is ready to “flip the switch” on January 1, take a sample of charts from each day’s billing and practice coding to 2021 standards as you complete the current billing workflow. Be sure to focus on key changes like Medical Decision Making and the revised Time component.
2.) Physician Involvement is Crucial
As you work through the simulated coding exercise above, be sure to involve your physicians with respect to their documentation. Your billing staff needs a thorough understanding of the new rules so they can share feedback with physicians and midlevel providers on where clinical documentation can be improved.
3.) Monitor the Process through the End of the Year
Start the simulated coding now, involve your providers early, and set a regular cadence with billing + clinical staff to review. It can’t be emphasized enough: practice makes perfect.
E&M Code Description Comparison: 2020 vs 2021
2020 Code Description
2021 Code Description
Office or other outpatient visit requires 3 key components:
- A detailed history;
- A detailed examination;
- Medical decision making of low complexity
Counseling and/or coordination of care provided are consistent with the nature of the problem. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
Office or other outpatient visit requires at least 2 of these 3 key components:
- An expanded problem focused history;
- An expanded problem focused examination;
- Medical decision making of low complexity.
Counseling and coordination of care with other physicians. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
2021 E/M Code Changes Guide – Working Example
A 77 year old gentleman (New Patient) presents today to evaluate gross hematuria for 3 days, with Fever. Physician has taken vitals and examined the GU, patient has normal scrotum, epididymis testicles. Patient was diagnosed with Gross hematuria, Lower Urinary tract infection secondary to BPH. Physician discussed the findings with the patient and prescribed medications.
2020 E/M Level – 99202
In 2020, this case would grade out as 99202. The 3 key components to assign the level are History- Expanded Problem Focused, Examination – Expanded Problem Focused, and Medical Decision Making – Moderate. RVUs total 0.93.
2021 E/M Level – 99204
Medical Decision Making alone is sufficient to assign the level. History – Medically Appropriate, Examination – Medically Appropriate, Medical Decision Making – Moderate. RVUs total 2.6.
2021 E/M Code Changes Guide – Medicare Proposed Work RVUs Table
2020 Work RVU
2021 Work RVU