Effective January 1, 2021, evaluation and management coding (E&M) guideline changes were finalized as part of the Centers for Medicare & Medicaid Services (CMS) 2020 Physician Fee Schedule, but these changes are reflected with all payers. Here are a few answers to some frequently asked questions about the E&M coding changes in 2021.

Why were these changes needed?

1995 and 1997 documentation guidelines have not changed drastically in over 25 years, and more simplified guidelines are needed to reflect current circumstances. (The 1995 and 1997 guidelines will continue to be used in hospitals, ER, observation, nursing homes, etc.)

Mid-level practitioners have flooded the healthcare market, resulting in more difficulties with the previous complicated coding process. Additionally, patient behaviors have changed: they don't visit their primary care physicians or specialists regularly. This can lead to some visits being more detailed than they may have been in the past.

CMS and the AMA effectively put these changes in motion to decrease documentation burdens, decrease audits and expand key definitions, decrease unnecessary documentation and ensure E&M payment is resource based.

There is no option to continue to use the 1995 or 1997 guidelines for new and established office visits. The 2021 guidelines are the compliant option.

What is the focus of the new guidelines?

Medical Decision Making (MDM) or time is the focus of these new guidelines.

MDM is the ordering of test, counseling, reviewing and collaborating with other health professionals and discussing treatment. Total time is an option in selecting the level of service. The guidelines allow documentation time (the day of the encounter) and other provider time in preparing for the visit, as well as the time spent with the patient face to face.

Practices still need the documentation to be meaningful by telling the story of the patient's visit, and data collection is an asset for practices that will still be obtained through updated documentation.

Are the codes changing?

The guideline change is taking place in the patient visit descriptions; the codes themselves are mostly unchanged. The 2021 guidelines will cover only 99202-99205 and 99211-99215.

The 2021 Code descriptions for CPT 99202-99205 and 99211-99215 no longer include the elements of history and physical exam to determine the level of the visit. If it's medically necessary to perform any extent of history or physical exam to treat the patient, it should be performed and documented.

While the new guidelines are flexible in the recording of the history and exam, it is still the basis of treatment. The new guidelines require a medically necessary history and exam but will not hold the provider to box checking in the EMR to meet a certain level of history or exam. All other E&M services are not changing.

Are criteria for new vs. established patients changing?

New patient visit descriptions will now use codes 99202-99205, and 99201 is deleted. Established patient visit descriptions 99211-99215 comprise 20% of all Medicare allowed charges, which gave these descriptions priority to be updated first.

Criteria for deciding if a patient is new or established will not be changing, meaning a new patient is defined as a person who has not received professional services from a physician in the same specialty in the same practice for three years. When the NP or PA is working with a physician, they are considered as working in the exact same specialty and the exact same sub-specialties as the physician.

Are the descriptions changing?

Some examples of E&M description changes include 99203 and 99213. These codes represent Office or Other Outpatient Services/New Patient and Office or Other Outpatient Services/Established Patient, respectively.

Both codes now allow for a medically appropriate history and/or examination along with a low level of medical decision making. 99203 and 99213 highlight how 2021's changes simplify the way physicians handle new and established patients.

How is clinical workflow impacted?

Every physician has a different workflow, even in a group practice. Some have scribes, some have a mid-level provider and often there are different ways to utilize the EMR. Some practices utilize a paper superbill, and others utilize the electronic superbill, which allows for the use of a coding calculator. All these workflows should be considered in preparing physicians for the changes in the coding guidelines.

How is reimbursement impacted?

The work Relative Value Unit (wRVU) for the new and established office visits is increasing. Specifically, the established office visit codes are increasing by 10-15%. It will be important for practices to monitor utilization patterns prior to the change and moving forward. Assure physicians are aware of the changes, and encourage them to improve documentation to support of the level of service. Diagnosis coding and proper use of ICD 10 will support the level of service. Using codes to reflect social determinants of health will support higher levels of service.

How can I learn more?

To learn more about these changes, you can view Warren Averett's webinar about the E&M changes at warrenaverett.com/EMOnDemand.

Tammie Lunceford, CMPE, CPC serves as the Senior Healthcare Consultant with Warren Averett.