To resuscitate what was often considered an ailing system, the Centers for Medicare and Medicaid Services (“CMS”) enacted substantial changes to physician office and outpatient Evaluation and Management (“E&M”) codes, documentation standards and payment methodologies. The proposed changes were issued in 2018; however, the most significant changes will not be implemented until January 1, 2021.
Almost one year after CMS issued Physician Fee Schedule (“PFS”) Final Rule 2019, the American Medical Association (“AMA”) released its “E&M Office or Other Outpatient and Prolonged Services Code and Guideline Changes”, which will also be enacted effective January 1, 2021. These changes put patients over paperwork by focusing on reducing the administrative burden of documentation and coding, thereby aligning with CMS changes. The AMA 2021 code set release will contain all new definitions, including new time ranges and level of Medical Decision Making (“MDM”) Table , which is similar to the Marshfield Clinic E&M scoring tool currently used by most payers. An overview of the significant changes is highlighted below.
I. E&M Guideline Changes per CPT Editorial Panel
Guidelines for observation, inpatient, consultations, emergency department, nursing facility, domiciliary, rest home, custodial care, and home E&M services will not change. Accordingly, the AMA plans to restructure the current E&M guidelines into three distinct sections:
Guidelines common to all E&M services.
Guidelines for observation, inpatient, consultations, emergency department, nursing facility, domiciliary, rest home, custodial care, and home E&M services.
Guidelines for office or other outpatient E&M services, outlining the new reporting guidance for E&M codes 99202-99215.
Summary of the differences between the existing and updated 2021 set of guidelines.
Addition of a new MDM table applicable to codes 99202-99215.
Addition of guidelines for reporting time when more than one practitioner performs distinct parts of the E&M service.
II. Office and Other Outpatient E&M Summary of Changes
CMS believes that the revised office/outpatient E&M guidelines issued by the AMA accomplished greater burden reduction than the initial CMS policies finalized for calendar year 2021 as presented in the 2019 PFS Final Rule. Accordingly, after soliciting comments surrounding the AMA’s Current Procedural Terminology (“CPT”) Editorial Panel changes in the proposed rule, the 2020 PFS Final Rule now largely aligns with the E&M coding changes laid out by the CPT Editorial Panel as follows:
1. Elimination of History and Physical Exam (“H&P”) elements for code selection
While the physician’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and MDM, these elements alone should not determine the appropriate code level. The joint AMA CPT workgroup on E&M revised the code descriptors to state providers should perform a “medically appropriate history and/or examination”. The following are the 2021 outpatient/office E&M CPT definitions:
New Patient
99202 - Office or other outpatient visit for the evaluation and management of a new patient, which requires medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
99203 - Office or other outpatient visit for the evaluation and management of a new patient, which requires medically appropriate history and/or examination and low level medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
99204 - Office or other outpatient visit for the evaluation and management of a new patient, which requires medically appropriate history and/or examination and moderate level medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
99205 - Office or other outpatient visit for the evaluation and management of a new patient, which requires medically appropriate history and/or examination and high level medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.
Established Patient
99211 - Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.
99212 - Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/or examination and low level medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/or examination and moderate level medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/or examination and high level medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.
2. Allow physicians to determine visit level assignment based on MDM or Total Time
MDM: The AMA CPT workgroup did not materially change the three current MDM subcomponents, but did provide extensive edits to the elements for code selection and revised/created numerous clarifying definitions in the E&M guidelines.
Time: The definition of time is minimum time, not typical time, and represents total physician and Qualified Health Care Professional (“QHP”) time on the date of service. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services like care coordination. As such, the definition of time is the total time personally spent by the reporting practitioner on the day of the visit, including both face-to-face and non-face-to-face time. These definitions only apply when code selection is primarily based on time and not MDM.
3. Modifications to the criteria for MDM
The CPT Editorial Panel used the current CMS Table of Risk as a foundation for designing the revised required elements for MDM. Current CMS Contractor audit tools were also consulted to minimize disruption in MDM level criteria.
Removed ambiguous terms (e.g. “mild”) and defined previously ambiguous concepts (e.g. “acute or chronic illness with systemic symptoms”).
Also defined important terms, such as “Independent historian.”
Re-defined the data elements to move away from simply adding up tasks to focusing on tasks that affect the management of the patient (e.g. independent interpretation of a test performed by another provider and/or discussion of test interpretation with an external physician/QHP).
The following chart depicts the MDM criteria comparison of definitions from current to 2021:
4. Retention of Five Levels for Established Patients & Four Levels for New Patients
In review of the CPT Editorial Panel’s new outpatient E&M CPT code descriptors, CMS found these recommended codes and values more accurately account for the time and intensity of office/outpatient E&M visits than either the current codes/values, or the codes/values finalized in the CY 2019 PFS Final Rule for CY 2021. Accordingly, CMS reversed the following elements from their original proposal:
Collapsed payment rate for office/outpatient E&M two (2) through four (4) visits;
Eliminated CPT 99201 since both 99201 and 99202 are straightforward MDM, differentiated only by history and exam elements which are no longer elements of the CPT definition.
5. Creation of a Single Shorter Prolonged Services Code
HCPCS code GPR01 (extended office/outpatient E&M time), previously finalized for 2021, was deleted because the time described by this code is instead defined by the updated level 3, 4, or 5 office/outpatient E&M base codes, and the single new add-on CPT code for prolonged services in this setting.
Further, under the new CPT framework, prolonged E&M CPT codes 99358-99359 will no longer be payable with office/outpatient E&M visits on the same date of service beginning in calendar year 2021. For prolonged service time (combining time with and without face-to-face patient contact) on the date of service of an office or other outpatient service, a provider will report 99XXX. CPT 99XXX, prolonged services add-on code, captures physician/QHP time in 15-minute increments to be reported when time is the primary basis for code selection for 99205 and 99215 only as per the following CPT definition:
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.
Table 33 (2020 PFS Final Rule) illustrates how prolonged office/outpatient E&M visit time will be reported. [i]
6. Office/Outpatient E&M Visit Revaluation
Following an extensive AMA survey and revaluation process of more than fifty (50) specialty types, CMS received valuation recommendations from the AMA Specialty Society Relative Value Scale Update Committee (“RUC”) for the revised office/outpatient E&M visit codes (99202-99215). Although these codes do not take effect until calendar year 2021, CMS finalized the RUC-recommended work RVUs for all of the office/outpatient E&M codes and new prolonged services add-on code. Table 35 (2020 PFS Final Rule) summarizes the current code set, including the new prolonged services code physician RVUs and total time compared to the CY PFS 2019 proposal. [ii]
Of note, since the updated values are not effective until CY 2021, CMS will consider additional information pertaining to valuation of these services if submitted prior to the February 10, 2020 deadline for CY 2021 rulemaking.
Further, CMS acknowledges the complexity involved to neutralize the increased values associated with the change since E&M visit codes account for approximately twenty percent (20%) of total professional expenditures. Since the impact of other policies for CY 2021 is unknown, CMS stated it was premature to finalize a strategy in the current final rule, but intends to consider and address these concerns in future rulemaking.
7. Revision of HCPCS Descriptor and Valuation for GPC1X and Deletion of GCG0X
CMS identified the following types of office/outpatient E&M visits which differ from the typical visits, and are not appropriately reflected in the current office/outpatient E&M visit code set and valuation:
Separately identifiable office/outpatient E&M visits furnished in conjunction with a global procedure;
Primary care office/outpatient E&M visits for continuous patient care; and
Certain types of specialty office/outpatient E&M visits.
The application of a multiple procedure payment reduction (“MPPR”) to the first category above was not finalized; however, to account for the other two non-typical visits, CMS consolidated two add-on codes; HCPCS GCG0X was deleted and GPC1X descriptor was revised as follows:
GPC1X – Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)
Further, the valuation for GPC1X was reconsidered in the context of the revised office/outpatient E&M visit code set and proposed values. The PFS Final Rule 2019 work RVU was increased from 0.25 to 0.33 for calendar year 2021.
These CMS changes, which will now be replicated by all payers, add complexities to each provider’s workflow. In addition, contractual and or payment changes may also be proposed by third party payers, to replicate the changes being implemented by CMS.While the primary focus is to simplify and streamline documentation requirements for established office or outpatient E&M services when relevant information is already contained in the medical record, practitioners who work in varying sites of service will also utilize the old guidelines when rendering care outside the practice such as the Emergency Department, hospital or nursing facility.
SunStone offers services specifically geared to assisting hospital based and independent multi-specialty physician groups manage the ever-changing professional regulatory environment. If you have any questions, please contact Joli Fitzgibbons, Senior Manager at jolifitzgibbons@sunstoneconsulting.com or Georgia Rackley, Senior Clinical Specialist at georgiarackley@sunstoneconsulting.com.
[i] Federal Register, Volume 84, No. 221, Friday November 15, 2019, page 62,849.
[ii] Federal Register, Volume 84, No. 221, Friday November 15, 2019, page 62,852.