Major Changes to E/M Coding Starting in 2021

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EM Coding

The coding and rules in Evaluation and Monitoring (E/M) are about to experience the most significant changes since their introduction in the 1990s. The revisions are only limited to new and existing outpatient visits (CPT codes 99202-99205, 99211-99215) and will take effect from  January 1, 2021, onwards. In the coming years, improvements to all E/M codes are expected.

Everyone in health care that assigns codes, handles health records, or pays claims, including doctors and trained health providers, coders, health information administrators, payers, health facilities, and hospitals, may be impacted by changes to the current and defined office/outpatient codes. An overview of the CPT 2021 reforms, as well as free E/M curriculum modules, has already been published by the American Medical Association (AMA). Soon, they intend on releasing more educational services.

Why The Changes?

The AMA collaborated with partners, including the AGA and our sister GI organizations, to develop E/M guidelines that reduce the criteria for reporting while simultaneously helping to distinguish payments based on the complexity of treatment. In the 2020 Medicare Physician Fee Schedule (MPFS) final regulation, CMS announced that it would follow the recommendation of the AMA as well as their proposed relative values for CPT E/M codes for 2021. Of note, with most office E/M codes effective Jan. 1, 2021, there will be small rate changes, which could help those who treat patients with complicated conditions.

The removal of code 99201 (Level 1 new patient access), the addition of a 15-minute extended service code that can be registered with 99205 and 99215, and the subsequent redesign of the office visit code selection are the most significant changes to office/outpatient E/M visits:

  1. History and physical removal as elements for code collection: While it is clinically important to acquire a specific history and conduct a relevant physical evaluation that leads to both time and medical decision-making, these elements would not factor in code selection. Instead, only patient decision-making or time can decide the code standard.
  2. Option to use medical decision-making (MDM) or complete-time as the basis of reporting of the E/M level:
  • MDM. 

Although three MDM subcomponents (number/complexity of problems, data, and risk) will still exist, substantial changes have been made to how these components are described and counted.

  • Time. 

The interpretation of time is no minimum time, not “face-to-face” time or standard time. The minimum time on the day of operation reflects cumulative physician/qualified health care provider time. This redefinition of time makes it easier for Medicare to better appreciate the work involved with non-face-to-face programs, such as coordination of treatment and record analysis. Of note, these concepts only apply where the option of code is time-based and not MDM-based.

  1. Adjustment of the MDM criteria: The new CMS Risk Table was used as the basis for the specification of the updated requested MDM components.
  • Terms. 

Erased vague words (e.g., “mild”) and established definitions that were formerly vague (e.g., “acute or chronic systemic symptom disease”).

  • Definitions.

Established the definition of important terms, such as “independent historian.”

  • Data elements. 

The data components were reinterpreted to shift away from merely incorporating tasks to concentrating on how certain tasks impact the patient’s management (e.g. independent analysis of a test conducted by another physician and/or conversation with another doctor on the interpretation of the test).

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