by Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
April 23rd, 2019
In 2018, Medicare announced their plans for revamping the Evaluation and Management coding structure and was met with
On March 8, 2019, the AMA posted the CPT Editorial Summary of Panel Actions for February 2019, which lists specific changes they intend to make to the E/M codes, effective January 1, 2021. Although the AMA plans to make significant changes to E/M, they in no way are as extreme as the original proposed Medicare E/M changes. Additionally, as the CPT Editorial Committee will meet again in May and also in September, we may see even more E/M changes following the summary from those meetings (May 9-11 and September 26-28).
What does this mean for the people documenting E/M services, assigning the code levels, and auditing them?
Right now, Medicare has published the 2021 E/M changes they intend to make and now, so has the AMA. We've all seen that when Medicare and CPT do not agree on the way in which a specific service, or group of services, should be reported, Medicare may produce HCPCS code(s) with specific guidance for Medicare contracted providers to follow. As any coder is well aware, when a provider is contracted with a payer, they must follow the guidelines and policies specific to the contract they have signed, whether or not it matches with the CPT guidelines.
Now that the AMA has published these changes, we must wait to see how Medicare responds to them. Will we end up with significant differences in E/M code assignation among multiple payers or will they all adopt the same changes? And what are the new AMA E/M changes?
Which E/M Codes are Affected?
The new AMA CPT E/M changes are specific to Office or Other Outpatient Services (99201-99205 and 99211-99215) codes and no others. Until adopted by other payers, including Medicare, they are specific changes to the CPT manual only. They include:
- Deletion of 99201
- New guidelines specific to 99202-99215
- Changes in component scoring for both new and established patient codes (99202-99215)
- Changes to the medical decision-making table
- Changes to the typical times associated with each E/M code (99202-99215)
Say Goodbye to 99201
The AMA is planning to delete 99201 from this set of codes. That is an official code deletion meaning it will no longer appear in the codebook after 2020. There are some situations in which you may still need to report 99201, such as states that will not immediately adopt the 2021 CPT code changes (e.g., workers compensation payers).
To ensure all parties involved understand there is going to be a different set of coding rules for 99201-99215, CPT plans to publish the new guidelines (specific to these codes) under their own section header in the Evaluation and Management section of CPT. Changes will include:
- Guidelines Common to All E/M Services
- Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care and Home E/M Services
- Guidelines for Office or Other Outpatient Services
- Section Overview: Identifying and explaining the new guidelines which are applicable only to the Office or Other Outpatient codes (99202-99205)
- Summary of Guideline Differences: Including a table that identifies the differences between the different sets of guidelines
- Revised existing E/M guidelines: Ensuring there isn’t any conflicting information between the different sets of guidelines
- Definitions and Terms
- Addition of a new Medical Decision-Making Table specific to 99202-99215
- Guidelines for reporting Time when more than one individual performs distinct parts of an E/M service
- Revision of the MDM Table to include Table 2 for Office or Other Outpatient Services-specific scoring information
Changes in Component Scoring
Although documentation of history and physical examination will still be required to some degree, the amount of history or number of body areas and/or organ systems examined and documented will not be part of the scoring used to determine the overall E/M level of service. Instead, medical decision making (MDM) or total time will be used to make that determination. Additionally, and as always, medical necessity for the level of service must be identifiable within the documentation. The AMA has made some changes to the titles of the subcategories in the MDM Table (as noted in the table below).
Again, these are the CPT changes; however, any payer contracts (e.g., Medicare or payers that follow Medicare guidelines) may require calculation in another way, so be mindful of those contracts when implementing E/M changes in 2021. Moving forward it might be a good idea to begin informing providers and staff of the upcoming changes to both CPT and Medicare and then follow closely for additional announcements from both the AMA and Medicare.