Evaluation and management in 2021: Part 1

By Alexander Miller, MD, September 1, 2020

The Office or Other Outpatient Evaluation and Management (E/M) Service codes will be extensively modified for 2021 and beyond.

How did we get here?

Impetus: The 2019 Medicare Physician Fee Schedule proposed rule recommended merging the new and established patient E/M office visit levels 2-5 reimbursements into one payment amount. CMS also proposed reductions in payment for codes reported with modifier 25 to cover the costs of the payment consolidation. This stimulated significant concern within the house of medicine and catalyzed opposition to the proposal. This generated a reassessment of the present E/M coding structure, which is complicated, convoluted, and not necessarily representative of the actual amount of work done by a physician or qualified health care professional (QHP).

With cooperation and participation of CMS, the American Medical Association (AMA) organized the E/M Workgroup, which included a dermatology representative, tasked with producing an equitable E/M coding solution that would more realistically capture the work done during an office outpatient visit while also simplifying the coding structure and satisfying CMS’ financial concerns. In turn, CMS deleted the proposed E/M code changes from the final 2019 rule, expecting that the house of medicine would generate an acceptable revision to the present E/M outpatient coding construct. This was done and CMS accepted both the revised definitions and the RVS Update Committee (RUC)-recommended code values.

Result: A coding structure that is substantially simpler and easier to conceptualize and implement than the present construct. Why is this only limited to office/outpatient E/M service codes? Because this is a massive coding shift, requiring proper implementation as well as evaluation of the implementation’s effects over time. Other, presently unaffected E/M service codes, such as for hospital inpatient, nursing facilities, etc., are sure to be evaluated in the future. In the interim, a dichotomy of E/M coding parameters will exist, with one construct used to report office, outpatient care and the present system for specifying E/M care provided in all other settings.

The AMA’s 2021 CPT^® manual has provided extensive guidance on the new office/outpatient E/M code definitions and code selection. Additionally, AAD members have the opportunity to learn about these changes via various platforms through a robust AAD educational initiative. Some of these items will be found on the Practice Management Center’s Coding Resource Center and will include free webinars, Derm Coding Consult articles, and the AAD’s annually updated coding resources such as the 2021 Coding and Billing Manual and the 2021 Principles of Documentation in Dermatology.

What is happening to the E/M codes?

• 99201 will be deleted

• 99202-99215: Revised code descriptors and coding guidelines

• Changes apply ONLY to office and other outpatient services codes

• NO CHANGE to the following E/M code descriptors and coding guidelines: Hospital observation, hospital inpatient, consultations, emergency department, nursing facility, domiciliary, rest home, custodial, home

What are the changes?

• CPT 99201 will be deleted

• Code selection will be determined by only two criteria:

  • Medical decision making (MDM) or

  • Total time on the date of the encounter

• History and physical examination will not be used for code selection.

The details:

Although history and physical examination (H&P) will not factor into code selection, they are essential to proper patient care. An appropriate H&P will still need to be done, as dictated by the patient’s presenting problems and general health state. Obviously, the H&P will continue to be documented in the patient’s record. The deletion of the H&P from E/M code selection criteria may serve to diminish irrelevant data aggregation for the sake of upcoding to a higher level of E/M service, a practice that has received considerable scrutiny from CMS.

2021 MDM levels:

Straightforward, low, moderate, high

MDM criteria:

• Number and complexity of problems addressed at the encounter

• Amount and/or complexity of data to be reviewed and analyzed

• Risk of complications and/or morbidity or mortality of patient management

Time:

• Total time spent evaluating/treating a patient on the day of the encounter, basically a sum of the items below:

  • Pre-service (before the in-person patient encounter)

  • Intra-service (during the in-person encounter)

  • Post-service (after the patient encounter)

• Exact time ranges provided for each code level

Implementation of the new codes will occur on Jan. 1, 2021. Stay tuned to the Academy’s educational initiatives on the 2021 office E/M changes, including future issues of Cracking the Code.

Example 1

Starting in 2021, I will need to minimally document the H&P, correct?

Answer: Not really correct. An appropriate amount of history and physical examination based upon the patient’s problem(s) will need to be documented in the patient record, just as it needs to be done now. However, it will not impact your billing level.

Example 2

Oh, no! Now what? How will I report my few 99201-qualifying new patient visits?

Answer: Utilizing the new MDM qualifying criteria, a straightforward MDM visit would be reported with CPT 99202. Otherwise, one could also report the visit based on total time spent dealing with the patient’s problem on the day of the visit.

Example 3

Things have been going well. I have finally become accustomed to feeding my electronic health records with information justifying a level of E/M visit, and now you are changing the entire E/M outpatient coding concept. Could we not just keep it the way it is?

Answer: No way! There was no option. CMS was intent on modifying the reimbursement scheme for outpatient E/M visits and was going to lead the change unless we, the house of medicine, offered another viable option. We, as physicians, had the choice of accepting something predetermined for us by CMS, or we could offer our own revision of the outpatient E/M coding and reimbursement via the established CPT-RUC system, which facilitates input from the house of medicine. Following a tremendous amount of effort that invited input from all medical specialties, the new outpatient E/M paradigms were fashioned by the AMA E/M Workgroup, and they were accepted by CMS.

Example 4

How will I find out all the details?

Answer: Stay tuned. The AAD will disseminate information via a multitude of communications platforms. It will be hard to miss — unless one is totally tuned out of published and electronic media.

Additional DermWorld Resources