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Summary of E&M Coding Changes

Beginning 1/1/2021

Background

The Relative Value Scale Update Committee (RUC) convened an E/M workgroup in February 2019 to study outpatient E/M codes and determine whether changes were warranted to this code set. ACP and several other medical societies were active participants in this workgroup that ultimately led to recommendations being developed into CPT Code description changes. These changes called for deleting 99201 (outpatient E/M, new patient), using time or medical decision-making (MDM) as the only elements of code selection, and realigning the time associated with these codes.

Following the acceptance of the CPT application by the AMA’s CPT Editorial Panel, the RUC undertook a physician survey of the outpatient E/M codes. The survey had the most responses in the history of the RUC process with nearly 1,700 physicians completing it. Following the completion of the survey and an evaluation of the results, specialty societies recommended, and the RUC accepted increased valuations for the outpatient E/M codes.

For more information on the history of this effort, check out the ACP Internist article.

What this means Beginning January 2021

Beginning January 2021, physicians billing for Medicare (not for commercial plans) patients will no longer have to use a patient’s history or physical exam to determine the appropriate level of E/M coding. While physicians are still required to perform a physical and determine a patient’s medical history, they will no longer have to use two out of the three elements (history, exam, and medical decision-making) to determine the level of E/M coding to bill. Instead, physicians can choose from either (1) time OR (2) medical-decision making to determine code selection.  

Using Time

Physicians billing Medicare may use total time on the day of the patient encounter to determine the level of outpatient E/M coding to bill. Total time This includes both the total face-to-face and non-face-to-face time spent on the date of the patient encounter by the physician and other qualified health care professionals. The requirement that 50% of the total time be spent providing counseling and/or coordination of care no longer applies beginning in 2021. The following activities will now count toward the total time:

  • preparing to see the patient (reviewing tests, etc.)
  • obtaining and/or reviewing separately obtained history
  • performing a medically appropriate examination and/or evaluation
  • counseling and educating the patient/family/caregiver
  • ordering medications, tests, or procedures
  • referring and communicating with other health care professionals (when not separately reported)
  • documenting clinical information in the electronic or other health record
  • independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • coordinating care (not separately reported)

Using Medical decision-making

Alternatively, physicians billing Medicare may continue to use medical decision making to determine E/M code selection. This involves the following three elements:

  • the number and complexity of problem(s) that are addressed during the encounter,
  • the amount and/or complexity of data to be reviewed and analyzed, and
  • the risk of complications, morbidity, and/or mortality of patient management decisions made at the visit associated with the patient’s problem(s), the diagnostic procedure(s), and treatment(s).

Once physicians have reviewed these elements, they are able to determine the level of medical decision making: straightforward, low, moderate, or high. In turn, this determination allows for the appropriate code selection. Please refer to the coding brochure on this page for more information.

Overview of Changes

Element Pre-2021 Post-2021
Time ✓*
Medical Decision-making
History X
Exam X

*More than 50% of the total face-to-face time must be spent in counseling and/or coordination of care.

Valuation Changes

The change in CPT guidelines and descriptors meant that a new survey of outpatient E/M codes was necessary. Following a robust survey of the revised code set, CMS largely accepted the proposed valuations for these services. 2021 Conversion Factor: $34.89. Below is an overview of the new valuations for these services beginning in 2021.

CPT Codes 2020 Non-facility RVUs 2021 Finalized Non-facility RVUs % change from 2020 2021 Medicare Payment Amount
99201 1.29 Code Deleted Code Deleted Code Deleted
99202 2.14 2.13 -0.5% $74.32
99203 3.03 3.28 8.3% $114.44
99204 4.63 4.93 6.5% $172.01
99205 5.85 6.51 11.3% $227.13
99211 0.65 0.68 4.6% $23.73
99212 1.28 1.67 30.5% $36.56
99213 2.11 2.68 14.1% $93.51
99214 3.06 3.81 27.0% $132.93
99215 4.11 5.33 29.7% $185.96

Documentation Exemplars for a Note Based on Time and MDM – Level 99214:

Below is an example of a chart note for outpatient E/M code 99214. Physicians may use this as a guide when determining how to document their work on a patient’s chart. Additional examples will be provided.

99214 Time-based Note 99214 MDM-based Note

Narrative created by patient answers to questionnaire and MA/nurse history:

Patient returns for follow-up of HTN and DM.  Doing well, no new complaints.  Taking meds regularly without SE or concerns.  Diet – maintaining low simple sugar, low added salt. 

-OR-

Physician Documentation: 

PE – unchanged from prior, except for tr ankle edema bilat

Assessment – doing well, understands chronic conditions, diet, exercise, meds

Spent additional time discussing how patient would not benefit from switching current healthy diet to a fad diet that was too high in saturated fats, including the additional risk of “yo-yo” weight loss.

Plan – continue current regimens. F/U for in 4 mo., sooner if need be.

Discussed and updated patient goals, spouse present for entirety of discussion. 

Narrative created by patient answers to questionnaire and MA/nurse history:

Pt returns for f/u of HTN and DM.  Doing well, no new complaints.  Taking meds regularly without SE or concerns.  Diet – maintaining low simple sugar, low added salt.  Exercise – walking 4x/wk. about 30 min/day.

No ED visits or hospitalizations since last visit

Other MD visits since last visit – cardiologist – no new diagnoses or meds.

-OR- 

Physician Documentation:

PE – unchanged from prior, except for tr ankle edema bilat

Assessment – doing well, understands both chronic conditions, diet, exercise, meds including continued atenolol

Plan – continue current regimens. F/U for in 4 mo., sooner if need be.

Billing Options for Time-based Note:

Option #1: determined by physician attestation:

“I attest I spent 32 minutes today on (include list of permitted activities), which includes face-to-face time with the patient.” 

Attestation time-based coding determination = 99214

Option #2: determined by EHR meta-data of 32 minutes:

EHR-calculated time-based coding determination = 99214

Option #3: determined by EHR meta-data of 27 minutes and physician attestation 

EHR-calculated time-based coding determination = 99213

“I attest I spent an additional 5 minutes talking with patient’s cardiologist (not including in EHR calculation) discussing use and dose of beta-blocker” 

EHR-calculated plus physician attestation time-based coding determination = 99214

Billing Options for MDM-based Note: 

Option #1: as determined by 2 stable chronic illnesses and prescription drug management discussed in “Assessment”

MDM-based coding determination = 99214