2021 evaluation and management coding updates

Each year brings changes to CPT codes but 2021 brings significant changes that will impact practice workflow. Managing your specialty practice’s reimbursement is an intricate process and proper coding makes all the difference.

What’s new in evaluation and management coding?

One of the biggest changes for 2021 is to evaluation and management (E/M) codes 99202-99215. These changes will only apply to office visits. Evaluation and management codes represent high volume services and they apply across specialties. It’s crucial to stay up-to-date on these coding changes, because mistakes could lead to compliance issues and missed payments.

As finalized in the CY 2020 PFS final rule, in 2021, CMS will be aligning E/M visit coding and documentation policies with changes laid out by the Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits, beginning January 1, 2021.  Changes include:

• Retains 5 levels of coding for established patients, reduces the number of levels to 4 for office/outpatient E/M visits for new patients, and revises the code definitions
• Revises the times and medical decision-making process for all of the codes, and requires performance of history and exam only as medically appropriate
• Requires providers to select the E/M visit level based on either Medical Decision Making (MDM) or time
• Adds two new prolonged services codes (with or without direct patient contact) to describe prolonged office and outpatient E/M service of 15 minutes beyond the total time of the primary E/M procedure (either CPT code 99205 or 99215)
  • CPT code 99417 and HCPCS code G2212 may only be reported when the E/M service has been selected based on time alone (not medical decision making) AND only after the total time of a level 5 service (either 99205 or 99215) has been exceeded
  • Please note: Medicare has assigned a status indicator of invalid to code 99417 and created G2212 - G2212 should only be reported for Medicare claims unless otherwise directed by a private payer
    • Practices should check the payer's policy for appropriate reporting guidelines

See the green box located on page 8 located in the CMS E/M Service Guide [PDF].

CMS will increase payment rates for office/outpatient E/M visits, including maternity services, emergency department (ED) visits, end-stage renal disease capitated payment services, and therapy evaluations.  However, these office visit payment increases, and a multitude of other new CMS payment increases, are required by statute to be offset by payment reductions to other—especially specialty—services, contributing to the 10.2% payment decrease in the 2021 Conversion Factor.

What is measured in medical decision making?

Starting in 2021, medical decision making and time will be the two key components for E/M codes delivered in office settings. 
Medical decision making looks at:

• The number of diagnoses or management options
• The complexity of data
• The risk of signification complications, morbidity and/or mortality

Two of these three must be measured. New criteria take into account whom the providers interact with for each test. It does not simply count the number of tests ordered.

Medical necessity supports medical decision making. Medical necessity is conveyed by a diagnosis. It documents the level of investigation and treatment the provider administers to the patient. Medical decision making is about the provider’s decision today to give a particular drug and what type of monitoring will be needed.

Time as evaluation and management factor

Time is the other main component of E/M codes. If activities related to counseling and/or coordination of care take up more than fifty percent of the visit, time is the main factor to qualify for a certain level of E/M services.

New patient code: 99202
Time range: 15-29 minutes
Established patient code: 99212
Time range: 15-29 minutes

New patient code: 99203
Time range: 30-44 minutes
Established patient code: 99213
Time range: 30-44 minutes

New patient code: 99204
Time range: 45-59 minutes
Established patient code: 99214
Time range: 45-59 minutes

New patient code: 99205
Time range: 60-74 minutes
Established patient code: 99215
Time range: 60-74 minutes

Time refers to the total visit time on the date of the patient encounter. One change is the ability bill for pre-exam and post-exam services in 2021, as long as you're not getting paid for those activities somewhere else.  Length of visits are now measured in ranges, not exact numbers. Once time parameters are met, prolonged services can be attached to the CPT codes 99202-99215. 

Time looks at the amount of time the billing provider spends to:

• prepare to see the patient
• obtain and/or review history
• perform a medically appropriate examination and/or evaluation
• counsel and educating the patient/family/caregiver
• order medications, tests, or procedures
• refer and communicate with other health care professionals (when not separately reported)
• document clinical information in the electronic or other health record
• independently interpret results (not separately reported) and communicate them to the patient/family/caregiver
• coordinate care (not separately reported)

The practice can only use provider time, not staff member time, when using time to select an office/outpatient E/M code and the add-on prolonged care code. It’s also important to remember time a provider spends consulting with other providers on a diagnosis cannot be double counted under both evaluation and management and time.  If a physician and another qualified healthcare provider see a patient simultaneously, that can only qualify as one time.

All these changes may be confusing but we are here for you. We want to empower specialty practices with important information to enable you to be confident in the accuracy of your coding, so you can strive for the maximum reimbursement to which you are entitled. 

Legal disclaimer: Information presented is done solely for informational and educational purposes. Information should not be relied upon for purposes of regulatory compliance or as a guarantee for increased revenues or practice successes or failures. Information provided herein does not constitute and should not substitute for legal advice; Practice should consult with its own legal and regulatory counsel regarding all applicable legal and regulatory requirements.