Orthopedic Coding Alert

Remember, there will be 1 fewer office/outpatient E/M code next year.

The new year is nearly upon us, and with it will come the slew of office/outpatient evaluation and management (E/M) code changes that you’ve been hearing about for all of 2020.

If you’ve been paying attention all year, you’ve got this; the rules haven’t changed since they were announced earlier this year. So, you can trust in what you’ve learned and go into 2021 with a positive outlook.

Here’s a look at the highlights in the office/outpatient E/M code changes. Be ready to apply all of the following changes to your office/outpatient E/M coding for all claims filed on or after Jan. 1, 2021.

The Demise of 99201

Remember 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …)?

Well, in 2021, you can forget it.

Why? With its redundant descriptor — the medical decision making (MDM) is the same as 99202 — the AMA decided that 99201 itself was also redundant. It’s been nixed and there’s no replacement code. The first-level code for new patient office/outpatient E/Ms is 99202 — but not the 99202 you know in 2020. (More on that later.)

Experts were wholly behind the AMA “disappearing” 99201, as it seems to have disappeared itself anyway.

Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America, says she cannot recall the last time she actually saw 99201 on a claim. “It’s elimination helps to align the descriptors more with the available levels of service. Also, having four levels of new patient services requires the documentation to clearly illustrate complexity of the patient’s case; there’s no middle ground,” explains Hauptman.

Enter Expanded Roles for Time, MDM

History and examination will still be required as the visit dictates, but they are no longer deciding components in the code choice for office/outpatient E/M services.

That honor goes exclusively to time and MDM; in 2021, you’ll use choose between them to decide your office/outpatient E/M level.

The AMA also altered what constitutes “time” spent toward overall office/outpatient E/M level, explained Jaci Johnson Kipreos CPC, CPMA, CDEO, CEMC, COC, CPC-I, president at Practice Integrity, LLC in San Diego.

“Time will be redefined from face-to-face time to total time spent on the day of the encounter,” Kipreos said during her AAPC webinar “E/M Guideline Changes: Orthopedics.”

Rundown: In 2021, you can count the following activities toward total E/M encounter time:

• Preparing to see the patient (eg, review of tests);
• Obtaining and/or reviewing separately obtained history;
• Performing a medically appropriate examination and/or evaluation;
• Counseling and educating the patient/family/caregiver;
• Documenting clinical information in the electronic or other health record;
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver; and
• Care coordination (not separately reported).

Experts were on board with this change as well.

“I do like the fact that [the AMA] changed the typical face-to-face time to total time spent on the encounter,” says Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “This would mean that the time factor would not have to be based on just on counseling.”

Holle is also behind the time expansion because of the difficulty of diagnosing some patients that end up with low-end history, exam, and MDM at the end of an especially long encounter. This may cause the injury to be just low MDM — even though the provider might take a comprehensive history and exam to rule out multiple problems. In 2021, using time to decide office/outpatient E/M level can better represent those encounters.

The Rise of New E/M Descriptors

As 99201 falls, there will be a wholesale changes to the remaining office/outpatient E/M code descriptors.

The history and exam portions of the E/M codes haven’t been written out of the new descriptors; but the revisions clearly indicate these elements’ new status. Here’s how all the (remaining) office/outpatient E/M codes will look in CPT^® 2021:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a 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.)
• 99203 (… which requires a 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.)
• 99204 (… which requires a 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.)
• 99205 (… which requires a 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.)
• 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.)
• 99212 (… which requires a 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.)
• 99213 (… which requires a 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.)
• 99214 (… which requires a 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.)
• 99215 (… which requires a 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.)