Managing 2021 Evaluation and Management Code Changes
/
It has been more than 25 years since Evaluation and Management (E/M) codes went through significant changes.
Beginning January 1, 2021, healthcare providers and medical billers must select E/M codes for office or other outpatient visits (99202-99205 and 99212-99215) based on the level of medical decision making (MDM) or total time spent on the patient encounter, and not the patient’s history and physical exam.
The 2021 E/M code changes, made by the American Medical Association® (AMA) Current Procedural Terminology (CPT®) Editorial Panel and the Centers for Medicare & Medicaid Services (CMS), aim to reduce the administrative burden of maintaining medical records—putting the patient above paperwork.
The E/M codes and descriptor changes provide an easier way to code office or other outpatient visits and rewards the time a healthcare provider spends evaluating and managing patient care.
Let’s take a closer look at the 2021 E/M code changes and how eye care providers should bill for office and other outpatient visits.
What Are Evaluation and Management Codes?
E/M codes is a category of CPT® codes used for billing services provided by a doctor or other healthcare provider. The E/M codes describe patient visits in various categories.
These medical codes apply to visits and services that involve “evaluating and managing” patient health for new and established patients. CPT® codes are published by the AMA that consist of three types or categories of five-character codes and two-character modifiers to describe any changes to the procedure.
Related: Common Medical Billing and Insurance Terms You Should Know
What Are the 2021 E/M Code Changes?
E/M code 99201 (Level 1) was deleted due to low utilization.
Healthcare providers will now select the appropriate level of E/M services based on what is more appropriate: medical decision making (MDM) as defined for each service or total time (minutes) for E/M services performed on the date of the encounter, NOT the patient’s history and physical exam.
While the history and physical exam elements are no longer required in selecting the office/outpatient level of service E/M code, they are still significant factors when reporting an E/M visit and must be documented in the patient’s medical record. The provider must establish medical necessity by documenting risk and medical decision making that is relevant to the patient’s condition.
The new 2021 E/M codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215) total time can qualify on its own (except for CPT 99211).
The “number of diagnoses or management options” changes to the “number of complexity problems addressed” for outpatient E/M codes.
The “amount and/or complexity of data to be reviewed” changes to “amount and/or complexity of data to be reviewed and analyzed” for outpatient E/M codes.
The “risk of complications and/or morbidity or mortality” changes to “risk of complications and/or morbidity or mortality of patient management” for outpatient E/M codes.
IMPORTANT REMINDERS: All other E/M services defined by the three key components (history, medical decision making, and exam) will continue to use the 1995 and/or 1997 Documentation Guidelines. Also, it is the provider’s responsibility to determine the appropriate E/M code and if the history and/or medical exam is medically necessary, and to what extent it is performed and documented.
How Does Total Time Relate to 2021 E/M Code Changes?
The AMA defines time for E/M coding as the total time (based on minutes) the healthcare provider spends on the date of the encounter.
Non–face-to-face activities, such as preparing for the patient’s encounter or ordering tests, are now recognized as billable time a physician and/or other qualified healthcare professional spends with the patient on the date of the encounter.
The terms “midpoint” and “threshold” are no longer used. Do not include the time a clinical ancillary staff person spends with the patient. If more than one provider treats the patient, only count one provider per minute.
New Patients Total Time
99202: 15-29 minutes
99203: 30-44 minutes
99204: 45-59 minutes
99205: 60-74 minutes
Established Patients Total Time
99212: 10-19 minutes
99213: 20-29 minutes
99214: 30-39 minutes
99215: 40-54 minutes
Prolonged Services Components
Prolonged services must meet time components (listed above) plus 15 minutes or more for each unit. For example, 99205 must meet 74 minutes plus an additional 15 minutes, and 99215 must meet 54 minutes plus an additional 15 minutes on the date of the encounter to qualify for prolonged services.
Add appropriate E/M prolonged service codes (99417 for commercial payers and G2212 for Medicare) separately according to your insurance payers to the claim.
Time-Based Coding Guidelines
According to the AMA, the 2021 E/M code changes apply to the new coding elements when a qualified healthcare professional performs the following services:
Reviewing a patient’s medical record (such as tests) before the visit
Obtaining and/or reviewing a patient's history from someone other than the patient
Performing a medically appropriate examination and history
Counseling and educating the patient, family or caregiver
Referring and communicating with another healthcare provider(s) when not separately reported
Documenting clinical information in the patient’s electronic health record (EHR)
Independently interpreting results (not separately reported) and communicating those results to the patient, family, or caregiver
Coordinating care for the patient
Ordering prescription medications, tests, or procedures
Pro Tip: Refer to the AMA CPT® E/M Code and Guideline Changes guidelines document for detailed information relating to office or other outpatient codes 99202-99215.
What Coding Elements Should You Use for Medical Decision Making?
“Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option,” reports the AMA. E/M codes recognize four types of decision making: minimal, low, moderate, and high.
You must meet or exceed the medical decision making level to qualify for that particular E/M coding level. The following three elements define medical decision making.
Number and complexity of problem(s) addressed during the encounter. A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other issue you note on the encounter. Problems are addressed or managed when you evaluate and treat the problem during the visit and might include further testing or treatment.
Amount and/or complexity of data (medical records, tests, etc.) you need to review and analyze for the encounter.
Risk of complications, morbidity, and/or mortality of patient management decisions made at the visit associated with the patient’s problems, diagnostic procedure(s), and treatment(s).
Pro Tip: Use the AMA CPT® E/M Level of Medical Decision Making Table to determine the appropriate office or other outpatient E/M service code.
Empower Your Eye Care Practice with Complete Medical Billing Services
Keeping up with medical coding and medical billing changes, insurance payer requirements, complicated electronic data interchange (EDI) processes, and managing rejected and denied claims is time-consuming and frustrating. The Fast Pay Health end-to-end revenue cycle management approach is to triple-check everything so that you see a consistent return on your investment.
Request a free practice analysis today and see how Fast Pay Health optometry and ophthalmology billing consultants take a proactive approach to help you get paid faster and improve the financial performance of your practice.
