Three things to know about the coming E/M coding changes

Editor's note: In its 2021 Medicare Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) released new guidance regarding coding for prolonged E/M services. This article has been updated accordingly.

The most consequential changes to evaluation and management (E/M) coding in decades are coming soon, and it’s time to prepare now. When they take effect Jan. 1, 2021, you will no longer need to document the patient’s history of present illness or exam components. Instead, you will be able to document office visit codes 99202-99215 using only total time or medical decision making. Coding for prolonged services will also be simplified.

Here are three things to know about the coming changes:

1. Total time includes all of the time you spend on that patient on the day of the visit. That’s right, you will now “get credit” for the time you spend prepping for the visit and time you spend documenting the visit and writing orders afterwards, as well as your face-to-face time with the patient. But get your documentation done before midnight on the day of the visit, because that’s the deadline for including it in total time. For established patients, a level 2 visit will be 10-19 minutes and a level 3 visit will be 20-29 minutes. The other thresholds can be remembered using the “30-, 40-, 55-Minute Rule” — level 4 starts at 30 minutes, level 5 at 40 minutes, and every visit of 55 minutes or above can be coded with a level 5 code plus the prolonged services code.

2. Prolonged services coding will also change. The multiple current codes will become a single CPT code, 99417, which you can bill in 15-minute increments when total time exceeds a level 5 visit. So, a visit of 55-69 minutes with an established patient would require 99215 plus a single 99417 prolonged services code. A visit of 70-84 minutes with an established patient would take a 99215 plus two 99417 prolonged services codes, and so on. CMS, however, has decided to allow physicians and other qualified health care professional to bill for prolonged services only when they have exceeded the maximum time for a Level 5 visit by 15 minutes or more (at least 69 minutes for an established patient and 89 minutes for a new patient), rather than the minimum time. Because of the discrepancy, Medicare has its own code, G2212, for reporting prolonged services.   

3. Medical decision making is made up of three elements: problems, data, and risk. Problems are the patient concerns you are addressing at that visit (the patient may have other problems, but you can only count the ones you’re addressing at the current visit). Data is every unique test, order, or document you reviewed for the visit. Risk is the patient’s odds of complications, morbidity, or mortality. The amount and complexity of the problems, data, and risk determine the level of visit. This table outlines the revised requirements.

Read the full article in FPM: “Countdown to the E/M Coding Changes.”