AMA releases CPT guidelines for E/M codes in 2021
There’s more clarity on what E/M coding will look like in the outpatient setting come 2021, thanks to a detailed set of CPT guidelines recently released by the AMA. The 16-page document, which is written as they will appear in the 2021 edition of CPT, clarifies many of the documentation simplification policies that both the AMA and CMS have set forth over the last year. CMS kicked things off with its Physician Fee Schedule (PFS) rule for 2019, announcing major changes to outpatient E/M coding, while the AMA later followed suit with corresponding plans to alter the E/M section of CPT.
In this article, we’ll dig into the new 2021 guidelines, analyze the changes, and highlight the specific instructions being provided in CPT so that coders, auditors, and providers have plenty of time to study up and prepare. Remember: The following changes will affect only 99211-99205 and will be effective starting Jan. 1, 2021.
Coding based on time
Selecting an E/M code based on time spent is currently reserved only for counseling-dominated visits, which the 1995 and 1997 E/M guidelines define as those visits in which more than 50% of the total face time was spent on counseling and/or coordination of care. From a compliance standpoint, auditors usually advise providers to avoid coding based on time unless the visit took noticeably more time than typical and the counseling requirement is being met. The guidelines also ask for a summary of the counseling, adding to the documentation burden of time-based coding. A final wrinkle was that some payers still required medical decision making or medical necessity to meet the resulting code level, even if the time and counseling requirements were met.
All of these requirements are going out the window in 2021, at least for those payers who choose to follow CPT to the letter. “Beginning with CPT 2021 and except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes,” the new guidelines state. “Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service.”
With the counseling requirement gone, so too goes the existing requirement that a summary of the counseling be documented. This requirement has often led to compliance headaches when providers rely on templated language (“macros”) that repeats the same counseling verbiage in every single note. In 2021, for the outpatient codes, we can do away with this issue.
Best of all, at least from the provider’s perspective: Time counted is no longer strictly limited to face time spent with the patient. Under the new guidelines, time spent on just about any activity directly attributable to the care of the patient for that encounter can be counted. The new guidelines state that “Physician/other qualified health care professional time includes the following activities, when performed:
- Preparing to see the patient (e.g., 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;
- Ordering medications, tests, or procedures;
- Referring and communicating with other health care professionals (when not separately reported);
- 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).”
What isn’t changing are the actual time thresholds associated with each level of service. To code 99215 based on time will still require a total time spent of at least 40 minutes, though it should be much easier to hit 40 minutes now that all the items above can be counted.
History and exam, now highly optional
The term “medically appropriate” has long been applied, at least in theory, to the history and exam components of E/M services by CMS and many private payers, but it’s never changed their view that their ought to be some quantification of what is “appropriate.” Thus we have the longstanding 1995 and 1997 documentation guidelines which are very prescriptive about history and exam requirements for code selection.
Now, the new guidelines more fully embrace the concept of “medically appropriate” by giving providers tremendous leeway in determining how much history and exam to capture. “The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified healthcare professional reporting the service. The extent of history and physical examination is not an element in selection of office or other outpatient services.”
Also, the guidelines go a step further than CMS did in the 2019 PFS final rule, in which the agency stated that a “minimum supporting documentation standard” would be applied to history and exam, and that standard would be equivalent to a level 2 visit, new or established based on code. So, for a new patient, an expanded problem-focused history and exam would need to be documented according to CMS. Assuming CMS doesn’t adopt the AMA guidelines, it will be slightly stricter, but even so history and exam will be marginalized in 2021, saving a significant amount of provider time.
Clarifying medical decision making (MDM)
The sidelining of history and exam means that time spent and medical decision making (MDM) take center stage. We have already discussed how the AMA has simplified the use of time to select a code level; under the new system, it’s possible that many providers may be able to code based on time now that non-face-to-face time can be included.
The other option is MDM, which gets a greatly expanded set of definitions and clarifications in 2021. The new guidelines provide definitions of terms used in E/M documentation that were previously absent from CPT. Below are some key examples of new definitions and why they help clarify MDM and code selection:
- Problem addressed. “A problem is addressed when it is evaluated or treated at the encounter by the [provider] reporting the service … Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation or consideration of treatment does not qualify as being addressed or managed.”
- Here the AMA makes explicit what providers can get credit for; a particularly bad habit of some providers is to list multiple problems in their assessment and plan, but not state any plan of care (e.g. test orders, medications, referrals, etc.) for those items. Now problems that are listed but not “addressed” as defined above will not receive MDM credit, period.
- Stable, chronic illness. “A problem with an expected duration of at least a year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (e.g., uncontrolled diabetes and controlled diabetes are a single chronic condition). ‘Stable’ for the purposes of categorizing medical decision making is defined by the specific treatment goals for an individual patient. A patient that is not at their treatment goal is not stable, even if the condition has not changed and there is no short term threat to life or function.”
- This is notable for the AMA defining what constitutes “chronic” in terms of duration. Also, the AMA clarifies that patients not at goal for a particular treatment plan are not stable, even if they have continuously not at goal over a long period of time.
- Chronic illness with exacerbation, progression, or side effects of treatment. “A chronic illness that is acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care.”
- Chronic illness with severe exacerbation, progression, or side effects of treatment. “The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care.”
- The notable new language for both of these definitions is the consideration of whether or not the problems may require “hospital level of care.” This could help providers determine what constitute “severe” vs. non-severe exacerbation.
Taken together, these changes mean that outpatient office visits should require much less documentation time by providers. The time-based coding option could be the biggest time-saver, assuming providers are accurately counting non-face-to-face time. The old compliance rule about medical believability still applies, however; if a provider bills 99215 using time, if the total time is unbelievable (say 30 instances of 99215 on one day, meaning 40 minutes times 30 patients for an unbelievable 20-hour workday), a payer audit is nearly assured. There will still be decisions for providers to make, such as how to implement one documentation system for outpatient visits and another system for inpatient visits (the inpatient E/M codes won’t change in 2021), but these CPT guidelines have made the picture much clearer, and preparation much easier.
Disclaimer: This blog post is not intended to provide any legal advice, guidance or opinion. The information contained in this blog post is a non-legal interpretation of statutes, acts, laws and should not and does not substitute for the advice, guidance or opinion of legal counsel. The author bares no liability and make no warranties for the information provided if implemented as is without confirmation of its applicability by the end user.
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