ZHealth Online Member Newsletter: December 29, 2020
2021 Physician Evaluation & Management (E&M) Billing
The finalized codes for outpatient/office encounters for 2021 have been revised to include the option of physician billing based on total time spent during that encounter or medical decision-making. Five levels will be retained for established patients, and four levels will be retained for new patients (by deleting code 99201). Medically appropriate history and/or exam elements will still be required to be documented but will not be used for level assignment. Add-on codes are provided for prolonged services. Additionally, there are changes to the medical decision-making table and the relative time associated with each E&M level. These long-awaited changes in E&M guidelines have been put into place and are effective for encounters beginning January 1, 2021, for office/outpatient reporting. These changes do not impact inpatient coding.
One significant change is that code 99201 has been deleted for 2021. To report this previous level one service, assign code 99202.
The most significant change is that prior to January 1, 2021, outpatient encounters required documentation of a combination of history, exam, and medical decision-making to determine the level of care E&M CPT code. Additionally, prior to 2021 the use of time as the determining factor for selecting the correct E&M CPT code was restricted to those encounters that documented greater than 50% of face-to-face encounter time was spent in counseling and coordination of care. An additional requirement was that the nature of the counseling and coordination of care also had to be documented. For 2021 office/outpatient encounters, these requirements have been removed, and time or medical decision-making alone may be selected to determine the E&M level of care for codes 99202-99205 and 99212-99215. Note that code 99211 cannot be selected based on medical decision-making (only based on time).
Although the history and exam elements are no longer the required criteria for level assignment in 2021, enough information about the current condition, signs, and symptoms must be documented to provide medical necessity for the encounter. The extent of medically significant history and exam is determined by the provider.
Time
Another significant change for 2021 office/outpatient encounters is that rather than being only face-to-face time, the time may also include non-face-to-face time related to the visit on the date of the encounter. Services that may be included in calculating time are as follows: reviewing test results, independently interpreting results, obtaining a relevant history, performing a medically appropriate exam, counseling patient and caregivers, ordering tests and medications, requesting consults, referrals to other physicians or other qualified healthcare providers, and documenting pertinent information in the patient’s healthcare record. The total amount of time spent on these services must be documented. Time includes only those services provided by the physician or other qualified healthcare professionals and does not include time spent by clinical staff performing services, such as patient check-in.
Counseling and coordination of care no longer need to be documented as the dominating factor for codes 99202-99205 and 99211-99215; however, counseling and coordination of care must still be documented as greater than 50% of the encounter for other E&M codes.
When reporting split/shared services, count only distinct time provided by the physician or other qualified healthcare provider. Overlapping time should only be counted for one or the other, but not both. For example, when both the physician and the non-physician practitioner are present with the patient, count that time only once.
Emergency department/emergency room (ED/ER) visits (99281-99285) are not included in the list of codes in which time may be the only factor for selecting the E&M level of care. These services are usually assigned based on acuity of care, rather than time. The provider time tends to be split among multiple patients, which makes it difficult to document actual time spent with each patient.
Medical Decision-Making for Office/Outpatient Services
Basically, medical decision-making (MDM) is a combination of establishing a diagnosis through the process of evaluation and testing to determine the appropriate course of action through utilization of risk assessment. It also includes the decision process for determining the appropriate site of care (e.g., hospital, outpatient, or other facility) for management of the current problem(s).
As was true in previous years, medical decision-making is based on three elements: number and complexity of diagnoses/problems addressed during the current encounter, amount and complexity of data that is reviewed or analyzed during this encounter, and the risk of complications, morbidity, or mortality related to management decisions during the current encounter. Consideration may be given to multiple conditions that are addressed during the encounter. However, comorbid conditions that are not being addressed or do not affect the number or complexity of data should not be counted for the purpose of establishing medical decision-making. This is a more complex method for determining the E&M code when compared to the use of time.
There are new definitions and guidelines for determining the MDM level for 2021 that are different from those used in prior years for office and outpatient reporting.
Number and Complexity of Diagnoses/Problems
- Problem—disease, condition (including injuries), or illness (including signs, symptoms, and complaints) addressed or managed by the provider during the current encounter. A diagnosis need not be established at the time of the encounter.
- Problem addressed—any problem that is managed, treated, or evaluated by the provider during the encounter. This does not include documentation of problems being managed by another provider or making referrals without evaluation by this provider during the current encounter.
- Minimal problem—problems that do not require the provider to be present, although the service is provided under the provider’s supervision.Self-limited or minor problem—a transient problem that runs a definite course but does not permanently impact the patient’s health (e.g., a common cold).
- Acute uncomplicated illness or injury—typically a self-limited or minor problem that has not resolved but is expected to with treatment. The risk of morbidity or mortality is low with anticipation of full recovery following treatment. Examples include simple sprains, cystitis, and allergic rhinitis.
- Acute illness with systemic symptoms—illness that involves systemic symptoms and carries a high risk of morbidity if left untreated. Systemic symptoms may be general symptoms such as fatigue or fever. They may also be single system symptoms such as those related to a urinary tract infection or pneumonia. Treatment is designed to alleviate symptoms and decrease the length of the time for the illness.
- Acute complicated injury—extensive injury that requires evaluation and treatment of a body system that is unrelated to the injured body part or organ with multiple treatment options and/ or carries risk of morbidity.
- Acute or chronic illness or injury that poses a threat to life or bodily function—includes an acute illness, exacerbation of a chronic illness, or acute complicated injury, all of which have the potential to result in death or impair bodily function without immediate intervention. Examples include myocardial infarction, respiratory failure, acute neurological change, and acute renal failure.
- Stable chronic illness—problem(s) expected to last at least a year or until the patient expires. This includes long-term conditions that may be at their optimal treatment goal and the mortality risk without treatment is significant. Examples include controlled diabetes mellitus and controlled hypertension.
- Chronic illness with exacerbation, progression, or side effects of treatment—problem(s) expected to last at least a year or until the patient expires. This includes long-term conditions that are not at their optimal treatment goal and are acutely worsening, have become poorly controlled, have progressed in severity and the provider intends to control the progression through supportive care, or side effects of medical intervention without requiring inpatient (hospital) care.
- Chronic illness with severe exacerbation, progression, or side effects of treatment— the severe progression or exacerbation of a chronic illness, or side effect of medical interventions as noted above but carry a high risk of morbidity and may result in inpatient hospitalization.
- Undiagnosed new problem with uncertain prognosis—problem with symptoms representing multiple possible diagnoses that which if left untreated carry a high risk of morbidity (e.g., breast lump).
Amount and Complexity of Data
- Test(s)—imaging, laboratory, psychometric data (measurement of a patient’s knowledge, skill sets and abilities, personal attitudes, education, and personality traits) and physiologic data (observation of variables attributable to normal functioning of body systems and subsystems). Note: Laboratory results for panels may only be counted as one test, rather than counting each of the individual components of the panel. Definitions related to the differences between single and multiple tests is provided in the CPT code set.
- External—refers to medical records, notes, messages, or test results received from an external (outside) provider, facility, or healthcare organization (hospital, nursing home, dialysis center, surgery center, etc.).
- External provider—provider who has an individual (single practitioner) practice, is from a different group practice, or is of a different specialty/subspecialty.
- Independent historian(s)—parent, guardian, medical surrogate, or other caregiver (e.g., spouse or homecare nurse) who provides additional medical history due to the patient’s inability to provide complete, accurate, and reliable information due to either mental or physical limitations. Sometimes more than one independent historian will be required due to information conflict or poor communication among multiple historians.
- Independent interpretation—separate interpretation for tests with a specific CPT code. This does not apply if the provider has previously separately reported the service. This interpretation does not require the standard report that would be necessary for billing the test. A notation of the findings/interpretation in the encounter record is sufficient.
- Appropriate source—non-healthcare professionals who participate in the patient’s management (e.g., lawyers, parole officers, social workers).
Risk
Risk is the assessment of the probability for, or consequence of, an event related to the current encounter. Risk represents the probable outcome or consequences of the problem(s) managed during this encounter and includes risk of complication, morbidity, and mortality. The level of risk is determined by the nature of the problem(s) based on the common understanding of providers of the same specialty. There is a shared understanding amongst providers in the same specialty for the terms “high,” “medium,” or “low” risk. Medical decision-making also includes the determination of risk associated with initiating a specific treatment, continuing a specific treatment, or foregoing a specific treatment based on the provider’s clinical judgement.
- Morbidity—the state of functional impairment (loss of abilities) anticipated to last for a substantial period of time and negatively impact the patient’s quality of life. This may include organ damage that is transient or permanent.
- Mortality—likelihood of patient demise
- Social determinants of health—socioeconomic indicators that impact the health of a patient (e.g., food or housing shortages).
- Drug therapy requiring intensive monitoring for toxicity—drugs that must be constantly monitored to keep them in a therapeutic range, as they have the potential to cause severe morbidity and death even when taken correctly. This intensive monitoring can be either short-term or long-term (not less than quarterly) depending on the therapeutic agent. Monitoring may vary based on the therapeutic agent. Some drugs are monitored with lab tests, others may be monitored with imaging, and still others may require physiologic testing. This monitoring is not to confirm the efficacy of the drug, but rather to ensure the patient has no adverse effects or toxicity.
Levels of Medical Decision-Making
There are four possible levels of medical decision-making. They are straightforward, low, moderate, and high. Each contains the three elements of the following: number and complexity of problems addressed, amount and complexity of data, and risk. The elements were previously discussed in detail. Code 99211 is not included in the medical decision-making table because this code does not require the presence of the provider. Only patient oversight is required by the provider for code 99211.
When deciding on a level, two of the three must be met.
New and Established Patients
