AMA to revise CPT’s E/M codes in 2021, following CMS
When CMS announced it was finalizing major changes to outpatient E/M codes in 2021, the agency effectively sent waves of changes rippling throughout the healthcare industry. One of the biggest such consequences was revealed in March, when the AMA’s CPT Editorial Panel announced plans to revise the CPT codes for E/M services.
The CPT changes will become effective in 2021, at the same time as the CMS changes, and will only affect outpatient E/M codes 99201-99215. The AMA has stated that these changes are intended to complement the CMS policies that will take effect in 2021.
Remember: In 2021, CMS will switch to a blended payment for outpatient codes 99202-99204 and 99212-99214, with a higher blended amount for the new patient visits to reflect the additional time required. The level 5 codes will have a separate, higher payment rate “to better account for the care and needs of particularly complex patients,” CMS said in its 2019 Physician Fee Schedule final rule. More consequentially, CMS will change its criteria for determining E/M code level in 2021, emphasizing medical decision making (MDM) and total face time spent with patients and deemphasizing the history and exam components.
Comparing CMS vs. CPT changes for 2021
While the AMA established CPT and has full authority to tweak its contents, the CPT rules aren’t always the final word, because payers ultimately determine which services get paid based on coding and documentation. That said, the AMA’s decision to complement the CMS changes in 2021 with almost matching CPT changes suggests the two organizations are in sync on the need for E/M coding to change.
Let’s take a closer look at the AMA’s changes, bearing in mind that the CPT Editorial Panel will meet at least twice more in 2019 (in May and September), which means the current revisions may change or additional revisions may be added.
- CPT: 99201 is deleted. Starting with the 2021 edition of the CPT manual, new patient office visit code 99201 will be gone – permanently deleted. It’s probably no great loss, since new patient visits that can’t support at least 99202 are rare. The established patient code 99211 will not be deleted, at least for now, and remains unchanged. CMS: In 2021, 99201 is basically ignored. It doesn’t get its own tier of payment nor is it part of the blended rate.
- CPT: New basis for determining code level. The key components will now be MDM or total time spent on the encounter (see below for details). CMS: The language from CMS is almost identical but does require face-to-face time rather than total time spent.
- CPT: Time definition is changed and relaxed. Currently, the definition of “time” with respect to supporting an E/M level based on time is face-to-face time between the billing provider and the patient. However, CPT is revising this definition to “total time spent on the day of the encounter.” This is a significant change as it would allow physicians to count non-face-to-face time so long as that time can be attributed to the E/M service for that specific patient on the same day. CMS: Crucially, CMS does not revise its definition of time for 2021. CMS will still count only face-to-face time to select an E/M level in 2021. However, CMS is eliminating its requirement that physicians must spend at least 50% of the face time on counseling and/or coordination of care, and document this explicitly. CMS will now allow E/M level selection based on a simple statement of total face time spent for the encounter.
- CPT: History and exam still required, but rules relaxed. The CPT revisions state that history and examination are removed “as key components for selecting the level of E/M service,” but adds the new language that “a medically appropriate history and/or examination must be performed in order to report codes 99202-99215.” The exact definition of “medically appropriate” could be a point of contention for audits that occur in 2021 and beyond. CMS: The Medicare policy is a little more prescriptive. For levels 2-4, CMS will require the history and exam to be documented at the level currently required for a level 2 code, meaning a problem-focused history without review of systems or past/family/social history, and a limited exam of the affected body area or organ system. For level 5 outpatient E/M codes, CMS hasn’t given a specific requirement so it would also need at a minimum the same level of history and exam as required for levels 2-4.
Ripple effects almost certain to touch private payers
With two of the biggest movers and shakers in coding and documentation standard-setting having acted decisively on E/M services, other industry stakeholders are sure to follow. Exactly what steps private payers may take, and how closely they choose to hew to the CMS provisions, remains one of the biggest unanswered questions as 2021 looms on the horizon.
Historically, private payers have tended to follow CMS policy, but not perfectly. In 2011, CMS finalized a rule to eliminate the consultation CPT codes with the stated goal of reducing confusion which arose when it was unclear whether patients were being referred for consults or handed off permanently in a transfer of care. Some private payers followed CMS on consults, replacing consult codes and presumably saving some money (consult codes carry a higher rate of reimbursement than the existing outpatient and inpatient E/M codes CMS replaced them with). Other payers elected to keep recognizing and paying for consult codes.
Ultimately, payers seem likely to base their decisions on the impact to their bottom line. If, under the new coding scheme in 2021, outpatient E/M costs remain flat, payers may well follow CMS. If they believe costs could rise, they may adopt some of the changes, such as the MDM guidelines, but reject others, such as the blended payment rate. Either way, with the AMA deleting 99201 and possibly inclined to make more changes before 2021, private payers will soon be forced to take action of their own.
— Grant Huang, CPC, CPMA (email@example.com). The author is Director of Content at DoctorsManagement.
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