CMS Final Rule Changes E/M Reporting Guidelines

by  Wyn Staheli, Director of Research
January 5th, 2021

Just when we thought we had figured out Evaluation and Management (E/M) reporting for 2021, CMS released their final rule and now we will need to make some adjustments. While CMS stated that they were adopting the AMA guidelines for E/M office or other outpatient services, they did make a few changes.

Prolonged Services Changes

Code 99417 is the new prolonged services code for office visits (9920599215). However, CMS will require using the following code INSTEAD of 99417:

G2212 “Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 9920599215 for office or other outpatient evaluation and management services)”

Even though this is for Medicare, there are some payers which state that they follow the Medicare guidelines. Therefore, you will need to check with individual payers and find out if they will be requiring 99417 or G2212 when billing prolonged E/M office services.

Visit Complexity Add-on

CMS has also created a visit complexity add-on code which may be reported, when applicable, with office visits. The new code is (emphasis added):

G2211 “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)”

As you can see, this is aimed at providers managing more complex patient conditions, either a single serious condition or a complex condition. While CMS is not limiting this to certain specialties, they do anticipate that it will be most common in primary care. The following example was found in the final rule:

A 68 year-old woman with progressive congestive heart failure (CHF), diabetes, and gout, on multiple medications, who presents to her physician for an established patient visit. The clinician discusses the patient’s current health issues, which includes confirmation that her CHF symptoms have remained stable over the past 3 months. She also denies symptoms to suggest hyper- or hypoglycemia, but does note ongoing pain in her right wrist and knee. The clinician adjusts the dosage of some of the patient’s medications, instructs the patient to take acetaminophen for her joint pain, and orders laboratory tests to assess glycemic control, metabolic status, and kidney function. The practitioner also discusses age appropriate prevention with the patient and orders a pneumonia vaccination and screening colonoscopy.

It is clear that in the above example, the provider is providing longer-term care managing multiple organ systems.

NOTE: Do NOT report G2211 when reporting an office visit (99202-99215) with modifier 25.

Keep in mind that since this is related to E/M services, verify with individual payers if they will be following Medicare guidelines and if they will allow this code. Also, when reporting this code, be sure that the documentation clearly identifies how that the visit meets the code criteria.

References:

CMS Final Rule Changes E/M Reporting Guidelines. (2021, January 5). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/cms-final-rule-changes-e-m-reporting-guidelines-36768.html

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