Neurosurgery Coding Alert

The new criteria for basing the E/M level on either MDM or time only applies to codes 99202-99215.

Beginning in January of 2021, you will see some changes to new and established patient/outpatient evaluation and management (E/M) codes 99202-99215. Now is the time to prep your neurosurgery practice for these upcoming changes so that you are ready for them when they go into effect next year.

Read on to learn more.

Editor’s note: This is a part of an ongoing series appearing this year in Neurosurgery Coding Alert to prepare you for the upcoming 2021 E/M changes. Stay tuned for more information.

Tip 1: Grasp Basis of 2021 E/M Office/Outpatient Code Selection

Currently, for new patient office/outpatient codes (99202- 99205) and established patient office/outpatient codes (99212-99215), you use three key components, history, examination, and medical decision making (HEM) to select the appropriate E/M service level. But, starting on Jan. 1, 2021, CPT^® will remove history and exam as key components for codes 99202-99215. Instead, your code selection will be based upon the MDM level or the total time the physician spent with the patient on that date of service.

Don’t miss: CPT^® will also update and revise their guidelines, which will further explain how coders should handle MDM and time in 2021.

Tip 2: Know Which Codes Will Be Impacted

The new criteria for basing the E/M level on either MDM or time only applies to office/outpatient codes 99202-99215. The leveling rules for E/M codes in other categories will remain the same.

Tip 3: Remember Importance of History and Exam

Although history and exam will no longer be key components for determining the level of E/M codes 99202-99215, this doesn’t mean that providers should not perform a history and exam.

The history and exam will still be important, and they are still needed elements, says Raemarie Jimenez, CPC, CIC, CPB, CPMA, CPPM, CPC-I, CCS, senior vice president of product at AAPC and coding liaison to the AMA CPT^® Editorial Panel. They just won’t be counted towards the E/M component.

“When you look at the revised CPT^® code descriptors for 99202-99215, the code descriptor includes ‘which requires a medically appropriate history and/or examination,’” Jimenez says. “So, they still understand from a clinical perspective, the history and exam play a critical role in understanding what’s going on with the patient. It’s just not going to be bulleted, counting elements. It’s whatever the provider feels is necessary to adequately treat that patient for what the presenting problem is or the reason for that encounter.”

You can find a lot of information in the history and exam that helps to support the information for MDM, according to Jimenez. Examples of this include the severity of the condition, which is going to be supplemented by the information found in the history and exam. Also, the status of a condition. Is it a chronic illness? It is stable? Is it exacerbated? Is it not improving? So, in some instances, we are going to be able to glean that information from the history and exam.

“As a coder, you are going to be looking at the entire record to get a total picture,” Jimenez says. “I wouldn’t just skip those elements [history and exam] in the medical record and move straight into medical decision making because that information is still important.”

Tip 4: Observe Timeline for Deleting 99201

Code 99201 will be deleted on Jan. 1, 2021. You can continue to report this code until its deletion date.

Why will 99201 be deleted in 2021? Because both 99201 and 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making…) involve the exact same type of MDM, having two codes with a straightforward level of MDM was deemed unnecessary. Also, 99201 is not an often-used code, so it makes sense to delete it.

Tip 5: Conquer New Time Guidelines

Starting in 2021, if you use the total time the provider spent with the patient on that date of service to level the service for codes 99202-99215, then you should know that CPT^® will be replacing the words “typical time” with the words “total time spent on the day of the encounter,” along with changing the standard time thresholds for each of the codes. The typical time currently included in the code descriptors only reflects face-to-face time. But since most office visits have some pre- and post-visit time involved, too, the change to total time on the date of the encounter will allow you to include those times in your code selection.

Here is a chart that outlines the current typical times as well as the times you’ll see in 2021:

Don’t miss: You’ll be able to include such factors in your time calculation as ordering medications, tests, or procedures, and time spent personally doing preauthorization work — as well as reviewing records before you see the patient on the same calendar date.

“This is a culmination of advocacy efforts by professional medical associations to address the ‘bulleted’ format of evaluation and management guidelines that dates back to 1997,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “Physician groups have long argued that the medical decision making is the dominant activity provided in an evaluation and management service. Rather than mandating certain history and examination documentation, physicians have stated that medical decision making will drive the clinically-appropriate history and exam needs to be performed (and subsequently documented).”