Have you checked out the new guidelines for CPT E&M office visit codes that became effective as of January 1, 2021? There are big changes and the new guidelines are much more user friendly, so please read on! (Hard to believe that the new coding rules actually make things easier for us!)
So…what exactly has changed? First, CPT 99201 has been deleted; as of January 1, 2021 it is no longer a valid code. The new guidelines for choosing an E&M code allow providers to use either medical decision making (MDM) or time when choosing the level of code. If you remember, in the past offices were required to use either the 1995 or
the 1997 guidelines to choose a level of code. Those guidelines relied heavily on HPI (history of present illness), examination and medical decision making. The importance of the exam and HPI has been left out of the criteria when choosing a level of E&M code; though providers are still required to document these components.
The new guidelines use MDM or time to determine the level of the visit. Let’s start with discussing time. Previously providers could only use time as the determining factor when it was a contributing factor in the visit. HPI, exam and MDM were still the main determinants and time could be used in some circumstances when documented
appropriately. Time was also only considered for provider face to face time with the patient, counseling and/or coordination of care.
Under the new guidelines, providers are able to include the entire time the provider has spent on the patient during that date of service. Time can now include the time the provider takes preparing to see the patient, obtaining and reviewing separately obtained history, the exam, counseling, ordering of tests,
medications, follow up, documenting in EMR, referring or coordinating care with other healthcare professionals, interpreting results and communicating with the patient and care coordination. Wow, that is quite a change!
For example, under the new CPT guidelines, time for 99203 is 30-44 minutes, 99204 is 45-59 minutes and 99205 is 60-74 minutes. When using time to determine the level of the E&M visit, the total minutes spent on the date of service must be documented in the office note, otherwise it will defer to medical decision making (MDM). Remember the
golden rule, if it wasn’t documented it wasn’t done.
The other option is to use medical decision making (MDM) as the guideline for the level of visit. The American Medical Association has published a handy table to help providers determine the MDM. A link to the document is here.
Medical decision making is broken down into four levels (same as before) straightforward, low, moderate and high. Detailed information on the definition of each level can be found in the chart referenced above. When reviewing the chart you will see 3 columns. To determine the level of MDM, you will need to match two out of the three
columns. Column 1: Number and complexity of problems addressed. Column 2: Amount and/or complexity of data to be reviewed and analyzed and Column 3: Risk of complications and/or morbidity or mortality of patient management.
Once you get a chance to review this new information, I am certain you will find it will be easier for your providers to obtain and accurately report a higher level of E&M code than they did previously.
Keep in mind that these changes are for codes 99202-99215 only. There has not been a change in coding guidelines for emergency room or inpatient hospital visits. When reporting for those services, the rules have not changed and you should refer to your CPT book for further details.
Until next time…Keep Calm and Code On!