Anticipating 2021: The big update to office visit E/M guidelines

August 7, 2020 / By Rebecca Caux-Harry

At the time I’m writing this blog, 2020 is a little more than half over. It has been a tough year so far, for so many reasons. I won’t get into those reasons because they are well documented elsewhere. Like so many of you, I’m looking forward to 2021 because our highly anticipated update to E/M documentation and coding guidelines for office and other outpatient visits will be live.

If you’re like me, you’ve been coding E/M services much longer than you ever expected. Now, it’s getting interesting. We know that the update only impacts two visit types: New and Established office and other outpatient visits. Those services are currently reported with codes 99201-99205 and 99211-99215.  We have a wide variety of additional visit types based on the location and status of a patient that are not impacted by this update. That makes things a little more complicated. I have assumed this change only applies to these two visit types so the update can be tested before rolling out to all visit types. Time will tell.

When CMS originally published their updated E/M guidelines, it included a flattening of RVUs and payment for levels 2-4 for both new and established patients. With pushback from the AMA, physicians and medical societies, CMS decided to remove this feature of the update. Additionally, we were told that we could continue to use the current 95 and 97 guidelines, but that has changed too. We now have two rather than four options for coding these visits: total time or medical decision making.

Coding based on time will be updated. Currently, the code descriptor specifies face-to-face time, but in 2021 the descriptors will include a time range and specify total time spent. Additionally, physicians will not need to specify that counseling and coordination of care dominated the visit to use time to support their level of care. This update is hugely beneficial to providers, as their time providing care will be reimbursed even when not face-to-face. Regarding documentation of time spent, guide the provider to state total time spent providing care, and some description of that care including any relevant medical data. I haven’t found anything specific from the AMA about documentation requirements.

When selecting a level of care based on medical decision making (MDM), the physician must include a clinically appropriate history and/or exam. This update is a vast improvement over current 1995 and 1997 guidelines which requires extensive documentation that might not be medically relevant in order to support an E/M code appropriate for the complexity. This update improves both patient and provider experience. The medical decisionmaking chart is similar to our current tool but has been updated. It is divided into three elements and we are guided to score MDM based on two of the three elements. Risk is one of the elements, but it is not subdivided. Unlike current guidelines, the new and established levels align perfectly. For example, a moderate MDM is coded either 99204 or 99214 depending on whether the patient is new or established, but familiarize yourself with the updates to the MDM table. We still have the same names for the levels: straightforward, low, moderate and high. MDM does not apply to code 99211, which is used to report physician or other qualified health care professional supervision of clinic staff performing a face-to-face service.

We will have a new Prolonged Services code to report with the office and other outpatient visit codes. It is, oddly, 99XXX.  This code reports time with and without direct patient contact and is reported for 15-minute increments. The official descriptor is:

99XXX Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)

(Use 99XXX in conjunction with 99205, 99215)                                                            

(Do not report 99XXX in conjunction with 99354, 99355, 99358, 99359, 99415, 99416) (Do not report 99XXX for any time unit less than 15 minutes)

This code is reported in multiples, secondary to the supported E/M visit code depending on the total time spent providing prolonged care. 

Because this is an AMA update to the CPT codes and descriptors, it is safe to assume that commercial payers will adopt these updates fully. The complete AMA  article can be found here. Additionally, you can find the “E/M is changing: Are you ready?” webinar playback from July 20 on the AMA website.

Rebecca Caux-Harry, CPC, is a professional fee coding specialist with 3M Health Information Systems.

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