NEW E/M OFFICE VISIT GUIDELINES PART III

Erika Stevens, CPC - Senior Professional Physician Coding Specialist Coding, MRA Leave a Comment

E/M office and other and other outpatient visit guidelines will be changing as of January 1, 2021. Below are further details regarding these changes: Read Part I and Part II of this blog for more information.

Major E/M revisions for 2021 regarding time of patient encounters include

  • Extensive E/M guidelines additions, revisions, and restructuring
  • Deletion of code 99201 and revision of codes 99202 – 99215
  • Significant components for code selection:
    • Medically appropriate history and/or examination
    • Medical decision making (MDM) or
    • Total time on the date of the encounter

 

Differences Between Time Guidelines 2020 vs. 2021

E/M time guidelines through December 31, 2020

  • Counseling and/or coordination of care dominates (over 50% of face-to-face time) the encounter with the patient and/or family
  • ONLY face-to-face time is counted

E/M time guidelines beginning January 1, 2021

  • Time can be used for code selection for office and outpatient service regardless of counseling and/or coordination of care provided
  • Time may only be used for code selection of the other E/M services when counseling and/or coordination of care dominates the service

 

Defining and Qualifying Time for Office and Outpatient E/M Services

Total Time” definition

  • Includes physician/other QHP face-to-face AND non-face-to-face time, such as:
    • Preparing to see the patient (i.e., chart review – including test results)
    • Obtaining and/or reviewing separately obtained history
    • Performing a medically necessary examination and/or evaluation
    • Counseling and educating the patient/family/caregiver
    • Ordering medications, tests, or procedures
    • Referring and communicating with other healthcare professionals (when not reported separately)
    • Documenting in the patient’s chart
    • Independently interpreting results and communicating results to patient/family/caregiver
    • Coordination of care
  • Time spent by clinical staff is NOT included
  • More than one clinician addressed (that is not separately billable)

Time associated with New Patient Office Visits (Total time on the date of encounter)

New Pt E/M Code Typical Time (2020) Total Time (2021)
99201 10 minutes Code deleted
99202 20 minutes 15-29 minutes
99203 30 minutes 30-44 minutes
99204 45 minutes 45-59 minutes
99205 60 minutes 60-74 minutes

 

Time associated with Established Patient Office Visits (Total time on the date of encounter)

Established Pt E/M Code Typical Time (2020) Total Time (2021)
99211 5 minutes Time component removed
99212 10 minutes 10-19 minutes
99213 15 minutes 20-29 minutes
99214 25 minutes 30-39 minutes
99215 40 minutes 40-54 minutes

 

Other services with revised and relocated time guidelines

  • Outpatient services (99241-99245, 99324-99328, 99334-99337, 99341-99345, 99347-99350, 99483)
  • Hospital observation services (99218-99220, 99224-99226, 99234-99236), hospital inpatient services (99221-99223, 99231-99233), inpatient consultations (99251-99255), nursing facility services (99304-99318)

 

Differences Between Prolonged Service Guidelines 2020 vs. 2021

Prolonged Services (99342, 99358, 99XXX) through December 31, 2020

  • Prolonged services codes with direct patient contact (99354, 99355) and without direct patient contact (99358, 99359)
    • First hour denoted by base code
    • Each additional 30 minutes denoted by add-on code
  • Currently, prolonged services of 30 minutes or less beyond the typical time of the E/M service is not reported separately

Prolonged Services (99XXX) beginning January 1, 2021

  • Shorter prolonged services code to capture each 15 minutes of critical physician/other QHP work beyond the time captured by the office or other outpatient service E/M code
    • Use only when the office/other outpatient code is selected using time
    • For use ONLY with 99205, 99215
    • Prolonged services of less than 15 minutes is not reported
    • Allows time to be used on the date of encounter for both face-to-face and non-face-to-face time

CPT Revision

Prolonged Service with or without direct patient contact on the date of an office or other outpatient service

  • 99XXX – Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)
    • Use 99XXX in conjunction with 99205, 99215
    • Do not report 99XXX in conjunction with 99354, 99355, 99358, 99359, 99415, 994126
    • Do not report 99XXX for any time unit less than 15 minutes

 

Total Duration of New Patient Office or Other Outpatient Services (use with 99205) Code(s)
Less than 75 minutes Not reported separately
75-89 minutes 99205 x1 and 99XXX x1
90-104 minutes 99205 x1 and 99XXX x2
105 or more 99205 x1 and 99XXX x3 or more for each additional 15 minutes

 

Total Duration of Established Patient Office or Other Outpatient Services (use with 99215) Code(s)
Less than 55 minutes Not reported separately
55-69 minutes 99215 x1 and 99XXX x1
70-84 minutes 99215 x1 and 99XXX x2
85 or more 99215 x1 and 99XXX x3 or more for each additional 15 minutes

 

NEW PT 1-14 min 15-29 min 30-44 min 45-59 min 60-74 min 75-89 min 90-104 min
Do not use time (99202 by MDM) 99202 99203 99204 99205 99205+ 99XXX 99205+ 99XXX x2
EST. PT 1-9 min 10-19 min 20-29 min 30-39 min 40-54 min 55-69 min 70-84 min
Do not use time (99212 by MDM) 99212 99213 99214 99215 99215+ 99XXX 99215+ 99XXX x2

 

Final Rule – 2021 Medicare reporting rules on prolonged services

  • CMS finalized decision to adopt CPT code 99XXX to report all prolonged time spent on the date of the primary office or other outpatient E/M visit (99205/99215)
  • Finalized Medicare 2021 reporting instructions that codes 99358, 99359 will no longer be reportable in conjunction with office or other outpatient E/M visits

 

Resources: AMA E/M Office Visit Changes

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