Evaluation and management in 2021: Part 2
Cracking the code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, October 1, 2020
Part 1 of this series on the 2021 evaluation and management (E/M) coding guideline changes, announced the restructuring of Office or Other Outpatient E/M codes in the 2021 CPT® Coding Manual. Part 2 provides more specific details about each of the newly defined E/M codes.
You may have noticed that Part 1 in this series mentioned that code 99201 has been deleted. Why? Well, presently, in 2020, the CPT-defined difference between codes 99201 and 99202 hinges upon distinctions in history and examination (problem focused versus expanded problem focused) areas, whereas the medical decision making (MDM) is “straightforward” for both. In 2021, code selection will be based solely upon MDM or total time, and the MDM for both 99201 and 99202 is straightforward. Therefore, the two codes would have had an identical MDM definition. Consequently, 99201 had to be deleted. Bye!
Well, then, how about CPT code 99211? Is it deleted for 2021? No, it is not. It is preserved, but somewhat modified. Since 99211 describes attention given to minimal problems for which the presence of a physician/ QHP may not be required, MDM is not factored into this code selection. Neither is time relevant, as a physician/QHP is not required, and time is only summed for services delivered by a physician/QHP.
Now, let’s consider "time." Presently, time may only be used for office visit code selection when over 50% of face-to-face time is spent on counseling/coordination of care. This requirement is deleted in 2021, such that time may be used without restriction. The concept of time for code selection has been refined from “typical” time spent face-to-face, to “total time spent on the date of the encounter.” This total time encompasses all the time (both face-to-face and non-face-to-face) personally spent by the physician/QHP dealing with the patient’s E/M problem(s) on the encounter date. Total time includes time in activities that require the physician/QHP and does not include time in activities normally performed by clinical staff. This time includes the following activities, when performed:
Pre-service work, such as obtaining and/or reviewing separately obtained history/laboratory data prior to a face-to-face interaction with the patient
Intra-service work, such as face-to-face patient work including performing a medically appropriate examination and/or evaluation and counseling the patient/family/caregiver and educating, charting
Post-service work, such as coordination of care, ordering medications, laboratory tests or procedures, referral letter writing, and documenting clinical information in the electronic or other health record by the physician/QHP
Each CPT code, 99202-99205 and 99212-99215, has defined time ranges, listed within the code descriptors. These should be used to select an appropriate code based upon time.
The 2021 CPT Office or Other Outpatient Services CPT codes are presented here:
| 2021 and beyond Office or other outpatient services New patient | 2021 and beyond Office or other outpatient services Established patient |
|---|---|
99201 has been deleted. To report, use 99202. | 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. |
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.◄ | 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.◄ |
| 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 of medical decision making. ►When using time for code selection, 30-44 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 of medical decision making. ►When using time for code selection, 20-29 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 of medical decision making. ►When using time for code selection, 45-59 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 of medical decision making. ►When using time for code selection, 30-39 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 of medical decision making. ►When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.◄ ►(For services 75 minutes or longer, see Prolonged Services 99XXX)◄ | 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 of medical decision making. ►When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.◄ ►(For services 55 minutes or longer, see Prolonged Services 99XXX)◄ |
Example 1
You spend five minutes reviewing outside medical records and the patient’s intake history prior to seeing a new nodulocystic acne patient face-to-face for 15 minutes. After the personal encounter, you spend an additional five minutes ordering labs and dictating a referral note. Your staff takes 10 minutes reviewing the iPLEDGE program with the patient and entering the patient’s data into the iPLEDGE website. You bill CPT 99203 based upon 35 minutes of total pre-, intra-, and post-service time.
Answer: Incorrect. The total aggregate time allowed for calculating an E/M visit based on time is limited to physician/QHP time, and not ancillary staff time. The total physician time for the visit is 25 minutes, which falls into the 15-29 minute time range for CPT code 99202. In this instance, selecting a code based upon MDM would have more precisely characterized the level of work done.
Example 2
In 2021, you visit and evaluate an established patient who is now living in a retirement home (assisted living facility). You submit CPT 99213 based upon the MDM level for the visit.
Answer: Incorrect. First, the service should be appropriately reported with a Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services CPT code 99324 – 99337. Second, only “office or other outpatient services” (office or outpatient or other ambulatory facility) are to be reported using the 2021 MDM or time coding criteria. All other sites of service, including hospital inpatient, emergency rooms, nursing facilities, assisted living facilities, and patient homes continue to have dedicated CPT codes that are selected based upon history, physical, and MDM or “typical” time ranges.
Example 3
Early in the morning you spend 10 minutes reviewing a pathology report. Included are microscope slides and a referral letter along with patient records for a patient scheduled to see you that afternoon. Immediately prior to seeing the patient in person, you review the new patient chart data for three minutes and then spend 20 minutes with the patient doing a complete skin examination and explaining the nature of the patient’s melanoma and a recommended treatment plan. Your staff schedules the patient for a therapeutic wide excision, and you take two minutes dictating a note to the referring physician. You report CPT code 99203 based upon 35 minutes of total time, including the early-morning data review.
Answer: Correct. Although the 10 minutes of time spent reviewing data and microscope slides did not immediately precede the face-to-face patient interaction, these minutes are still counted toward the total physician/QHP time, as time is determined by the total time on the day of the encounter.
