Evaluation and management code changes for 2021

H. Thomas Johnson, MD, FAASM, Coding and Compliance Committee

Because of the pandemic this year, we have had lots of changes to our practice. Some changes include a focus on utilization of personal protective equipment, keeping our work areas cleaner, maximizing virtual visits, and increasing the use of home sleep apnea testing. More changes are around the corner with the 2021 implementation of evaluation and management (E/M) coding changes.

In 2018, the Centers for Medicare and Medicaid Services released proposed rules on coding changes that were later opposed by 170 medical organizations including the American Medical Association. This led to the formation of the AMA Evaluation and Management Work Group. This was a multispecialty group with representation from the AMA/Specialty Society Relative Value Scale Update Committee (RUC) and the Current Procedural Terminology Advisory Committee. They wanted to collect stakeholder input on coding structure, reduction of administrative burden, and appropriate valuation. The goal was to submit a code change proposal for review by the CPT Editorial Panel in February 2019. The committee was successful, and CMS published revised E/M coding to start in January 2021.

There are a few significant changes. The first one is that the history and physical is no longer used to select an appropriate E/M code. This is to help decrease the medical record documentation that is not required for patient care. It is important to note that although it is not required for billing, documentation of the appropriate history and physical is still necessary so other providers are informed when they review your notes. Second, the E/M code 99201 will be deleted. This is a new level 1 visit, which was rarely used. Third, E/M codes will be selected based on total time or medical decision-making. Finally, a prolonged service code to capture time in 15 minute increments was created with codes 99205 and 99215 when total time is used for code selection.

If a code is used based on total time, it would include the amount of time spent on the date of the encounter, not just the time spent in the room with the patient. This would include time before the visit reviewing patient records, time in the room performing the history and physical, and time after the visit finishing the documentation. CMS might change these times prior to the implementation on Jan. 1, 2021, but currently the ranges are below:

New Patient

• 99202 – 15-29 minutes of total time is spent on the date of the encounter
• 99203 – 30-44 minutes of total time is spent on the date of the encounter
• 99204 – 45-59 minutes of total time is spent on the date of the encounter
• 99205 – 60-74 minutes of total time is spent on the date of the encounter

Established Patient

• 99211 – May not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.
• 99212 – 10-19 minutes of total time is spent on the date of the encounter
• 99213 – 20-29 minutes of total time is spent on the date of the encounter
• 99214 – 30-39 minutes of total time is spent on the date of the encounter
• 99215 – 40-54 minutes of total time is spent on the date of the encounter

Medical decision-making can also be used for code selection. For all of the E/M codes, it is required to have at least two  of the following three elements: the number and complexity of problems addressed; the amount and/or complexity of the data to be reviewed and analyzed; and the risk of complications and/or morbidity or mortality of the patient. All three elements are measured as minimal, low, moderate, or high.

Another positive aspect of the CMS changes is that the value of most E/M codes has increased. This will result in a higher work RVU productivity for a high percentage of patients.

Overall, the E/M code changes for 2021 implementation are positive and should help meet the goal of decreasing medical record documentation that is not needed for patient care. Be sure to familiarize yourself with the changes. For more information, watch the coding and compliance webinar that is available as a free member resource in the AASM online store.

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