2021 E&M GUIDELINE CHANGES Updated-3/12/2021

PRESENTED BY LAURA B CONLAN, CPC DISCLAIMER

This educational product was current at the time it was published or released for viewing.

This educational product was prepared as a service to the public and is not intended to grant rights or impose obligations. This educational product may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

The Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements, as well as CPT and ICD-10-CM guidelines. E&M CHANGES IN 2021-OVERVIEW • Changes apply only to office and outpatient services-99212 through 99205

• Extensive E&M guideline additions, revisions, and restructuring

• Deletion of code 99201 and revision of codes 99202-99215

• Components for code selection: • Medical decision making-MDM Or • Total time on the date of the encounter THE LEVELING OPTIONS

• MDM • Extensive clarifications have been provided in the guidelines to define elements of MDM • Based on three elements • Number and Complexity of Problems Addressed - element 1 • Amount and/or Complexity of Data to be Reviewed and Analyzed - element 2 • Risk of Complications and/or Morbidity or Mortality of Patient Management - element 3 • Documentation requirements for history and exam are now as “medically appropriate” decided by the provider on the date of service at the encounter. This will no longer be a scored measure for level. • Time • Includes both face-to-face and non-face-to-face time • Clear time range for each code • In addition new prolonged service code for use when time based coding only. • CPT – 99417 – only to be used with level 5 CPT(99215, 99205) • or • HCPCS - G2212 – for report to CMS only to be used with level 5 CPT(99215, 99205) • Must meet 15 minutes in order to code the add-on. Do not report and time unit less than 15 minutes TIME INCLUDES THE FOLLOWING IN 2021

Physician/other qualified health care professional time includes the following activities, when performed: ▪ preparing to see the patient (eg, review of tests) ▪ obtaining and/or reviewing separately obtained history ▪ performing a medically appropriate examination and/or evaluation ▪ counseling and educating the patient/family/caregiver ▪ ordering medications, tests, or procedures ▪ referring and communicating with other health care professionals (when not separately reported) ▪ documenting clinical information in the electronic or other health record ▪ independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver ▪ care coordination (not separately reported) TIME RANGES FOR TIME BASED CODING IN 2021

Est. Patient CPT's New Patient CPT's CPT 2020 Typical time CPT 2021 Time CPT 2020 Typical time CPT 2021 Time 99211 99211 99201 10mins 99201 DELETED 99212 10 mins 99212 10-19mins 99202 20mins 99202 15-29mins 99213 15mins 99213 20-29mins 99203 30mins 99203 30-44mins 99214 25 mins 99214 30-39mins 99204 45mins 99204 45-59mins 99215 40 mins 99215 40-54mins 99205 60mins 99205 60-74mins PROLONGED SERVICE CODES

CPT 99417 - Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)

HCPCS 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 additional15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services) EXAMPLES OF PROLONGED SERVICE CODES

Total duration of New Patient Office or Total duration of New Patient Office or other outpatient services(use with 99205) Code(s) other outpatient services(use with 99205) Code(s) less than 75 minutes Not reported separately less than 89 minutes Not reported separately 75-89 minutes 99205 X 1 and 99417x1 89-103 minutes 99205 X 1 and G2212x1 90-104 minutes 99205 X 1 and 99417x2 104-119 minutes 99205 X 1 and G2212x2 99205 X 1 and 99417x3 or more for each 99205 X 1 and G2212x3 or more for each 105 or more additional 15 minutes. 120 or more additional 15 minutes. Total duration of Est. Patient Office or Total duration of Est. Patient Office or other outpatient services(use with 99215) Code(s) other outpatient services(use with 99215) Code(s) less than 55 minues Not reported separately less than 69 minues Not reported separately 55-69 minutes 99215 X 1 and 99417x1 69-83 minutes 99215 X 1 and G2212x1 70-84 minutes 99215 X 1 and 99417x2 84-99 minutes 99215 X 1 and G2212x2 99215 X 1 and 99417x3 or more for each 99215 X 1 and G2212x3 or more for each 85 or more additional 15 minutes. 100 minutes or more additional 15 minutes. HCPCS CODE G2211

Per CMS; “We are also clarifying the definition of HCPCS add-on code G2211(formerly referred to as GPC1X), previously finalized for office/outpatient E/M visit complexity, and refining our utilization assumptions for this code. In the proposed rule, we assumed that this code would be reported with 100% of office/outpatient E/M visits by specialties that rely on office/outpatient E/M visits to report the majority of their services. Because we think it may take some time for practitioners to begin reporting HCPCS add-on code G2211, for CY 2021, we are assuming that it will be reported with 90% of office/outpatient E/M visits by specialties that rely on office/outpatient E/M visits to report the majority of their services.”

This new code was created to account for the time, intensity, resources involved in a practitioner's collaboration and continuous care planning with the patient in addition to an Evaluation and Management service. –ASCO MDM-MEDICAL DECISION MAKING

In the new grid you can see each level is the same for New and Established codes. • Straightforward • Low • Moderate • High

• You need two elements of the three in order to select your level in accordance to MDM guidelines.

• The chart lays out the requirements necessary to achieve the level of service provided.

• The table looks a lot like the previously utilized table of risk.

LET’S PUT IT INTO ACTION-ELEMENT 1

Upon reviewing the assessment and plan for the note, Annie noted that the diagnoses list included the following:

Tonsillitis Pharyngitis Fever Cough Atrial Fibrillation Personal history of breast cancer

The history indicates that the patient presented for sore throat with fever and cough for which the plan of care states antibiotics were prescribed along with general advice. No further treatment or plans were documented as part of this encounter.

Which of the following levels are supported by the Number and Complexity of Problems Addressed ONLY(element 1):

A. Straightforward B. Low Rationale: C. Moderate B: LOW- The presenting problem is stated as the only problem treated according to the D. High documentation of the encounter. While it is possible that the provider considered the other diagnoses when rendering a treatment plan, this cannot impact the assigning of the level of service if that thought process is not documented (page 3, paragraph 6). The pharyngitis, fever and cough are sign/symptoms of the presenting problem and would not be additionally consider in the scoring process of the diagnosis. The presenting problem would be considered an acute, uncomplicated illness according to AMA Guidance (page 4, paragraph 2) LET’S PUT IT INTO ACTION – ELEMENT 2

While reviewing, Jenny made a list of the work of the encounter documented by Dr. Johnson throughout the encounter. The patient is a resident at an Assisted Living Facility and is accompanied by her daughter for the visit. Review the list and analyze the appropriate level noted for the Amount and/or Complexity of Data to be Reviewed and Analyzed:  Due to the patient’s dementia, Dr. Johnson documented that the daughter provided interval history and updates as to the patient’s health

 Dr. Johnson documented a call with the ALF providers discussing the patient’s rooming environments and the impact on her physical and mental stability at this time What level for the column of Amount and/or Complexity of Data to be Reviewed and Analyzed (element 2 only) is supported?

A. Straightforward B. Low/Limited C. Moderate D. Extensive/High Rationale: C: Moderate-The documentation indicates that both bulleted elements of work are noted on the new AMA MDM table. Dr. Johnson documented the input of the daughter during the encounter. This falls into the obtaining history from an independent historian into category 2 on limited or low MDM, meeting 1 of 2 requirements for categories on that level. However, the provider documented his call with the ALF as part of his management and expectations for this patient. This meets category 3 requirements for moderate level selection, in moderate level you only need 1 of 3 categories met entirely, so this meets that requirement. LET’S PUT IT INTO ACTION-ELEMENT 3 Chief Complaint: New patient to establish care The patient is a new relocation to the area and is here to establish care with our practice. She is relatively healthy individual with the only health issue being diabetes which is well controlled with her current dosage of Metformin. She has had diabetes for approximately 10 years and only notes fluctuations in her sugars at mealtime.

Impression: Diabetes, well controlled

We will establish care for this patient and begin managing her prescriptions and all management of her diabetes as well as all of her healthcare needs. I will continue the Metformin 850 mg every day as this is currently managing her diabetes appropriately. I have given her a 6 month prescription for this. She recently had her labs drawn with her previous provider- so we will hold on ordering those for now.

A. Straightforward/Minimal B. Low C. Moderate D. High

Moderate: Diabetes requiring prescription drug management would represent a moderate risk. The guidelines within AMA indicate that prescription drug management is management option representing moderate level risk. Prescription management is the act of initiation, discontinuation, modification, or continuation of a medication that requires prescriptive authority. This is the first visit with the orthopedic provider. He reports that he fell a couple of months ago and hit his right elbow. After this incident, the elbow remained swollen for about a month. He has fallen two or three times since then and hit his right elbow every time he has fallen. He has tried ibuprofen with little pain relief.

Past medical history includes anemia, iron deficiency, anxiety disorder, BPH, colonic polyps, depression, ED, hypertension, tremor, GERD, hyperlipidemia, obesity, OSA, mild dementia, RLS. Medication list reviewed today. No known allergies Patient is married, does not drink or smoke cigarettes. He is an electrician. Immunizations are all up to date. ROS: HENT: no headaches Cardiovascular: no chest pain Respiratory: no shortness of breath GU: no frequency Neurologic: no tingling or numbness Musculoskeletal: positive for joint pain and swelling in right elbow. No muscle pain. Examination: Constitutional: well developed, alert, in no acute distress Musculoskeletal: Spine: no spinal tenderness or misalignment, paraspinal muscle strength and tone within normal limits. Right upper extremity: moderate tenderness to palpation present-elbow region as well as a large amount of edema (size of a baseball). Elbow joint range or motion mildly restricted. Assessment: Olecranon bursitis of right elbow PLAN: Medications: Medrol (pak) 4 mg oral tablets, dose pack SIG: take as directed for 6 days DISP: (1) 21 ct dose-pack with 0 refill Instructions: • Suspect he will need joint aspiration and glucocorticoid injection • Ace bandage applied directly to the area of swelling; loose enough not to impede movement. Encouraged to leave the wrap on throughout the day. Do not put direct pressure on the joint. Full extension may relieve discomfort. • Motrin every 8 hours for discomfort prn Rationale:

This new patient presented with elbow pain which was not causing systemic problems. The presenting problem is an acute, uncomplicated injury. There are no documented tests or history obtained from another source, so no credit is given in the amount/complexity of data to be reviewed and analyzed. A prescription was given for a Medrol pak which warrants prescription drug management in the moderate category for risk of complications. Since two of three of the elements must be met, this visit is supported as a new patient, 99203.

LET’S LOOK AT ONE WITH TIME APPROACH Established patient presents for follow-up of 10 days of urinary symptoms. The total time of the encounter included 25 minutes that included review of previous notes, labs, and studies, face-to-face services, documenting the encounter, and submitting lab requisitions and e-prescribing. Symptoms are worsening with visible hematuria once yesterday in addition to retention and burning upon urination. Some nausea without emesis or abominable pain. No discharge from the penis, fever, chills, or sweats. No lesions in the groin area.

On exam, no lymphadenopathy, heart RRR, abdomen with bowel sounds, soft nontender- no guarding and no palpable organomegaly.

Documentation included orders for UA and ultrasound testing along with findings for each. An order was noted for CBC with Different PSA and Urine for chlamydia/gonorrhea

Plan Noted: Follow up in 1 week to review lab work Patient advised to always practice safe sex by using a condom. Urine negative for UTI, so at this time we will await labs and testing results for further treatment options.

Patient: Jonny Doe HPI History of Present Illness Details: Patient is a 20-year-old male who around a month ago had pain in the left lower abdomen. A few days after that he had a CT scan of abdomen and pelvis which revealed a 6-7 mm appendix without any evidence of appendicitis. Patient denied having had any pain in the right lower abdomen at all. He has not had any pain in his abdomen after that 1 episode in the left lower abdomen. In the office today he was quite comfortable and did not have any abdominal pain. No nausea, no vomiting, passing gas and having normal bowel movements. Thyroid nodule General Surgery Labs: Thyroid Stimulating Hormone (TSH) Thyroxine (T4) Total Triiodothyronine ROS Details: Gen. - denies fever or fatigue. Respiratory - denies shortness of breath. Cardiac - denies chest pain or palpitations. GI - as per the history of present illness. Exam Details: Alert awake oriented x3 Abdomen - soft, non-tender, non-distended. Assessment & Plan R10.32 - Left lower quadrant pain Plan Patient had 1 episode of left lower abdominal pain around a month ago and has not had any pain since then. He denied having had any pain in the right lower abdomen and his CT scan revealed a 6-7 mm appendix without any evidence of appendicitis. I do not believe that patient's pain was secondary to appendicitis. His appendix on the CT scan is still within the normal range of appendiceal size and has no evidence of appendicitis and therefore no surgical intervention is required. I discussed the above-mentioned with the patient who expressed good understanding and asked appropriate questions which were answered to his satisfaction. Level of Care Code 99202 New Patient Level 2 Diagnoses Left lower quadrant abdominal pain R10.32

Patient: Jon Doe History of Present Illness Details: 36-year-old male presents for evaluation and management of skin cyst on left side of upper neck. Cyst Symptoms: No Drainage, No Fever, Yes Mass/swelling, Not Painful, No Redness and No Trauma Duration: Yes > 1 year Thyroid nodule General Surgery Labs: Thyroid Stimulating Hormone (TSH) 1.098 uIU/ML (0.470-4.200) 04/03/20if previously ordered by yourself this would not count towards data as the review portion of a test is included in the order as implied. Thyroxine (T4) Total Triiodothyronine Visit Reasons: L side of neck sebaceous cyst Nurse Note: Pt state lump under left jaw bone, has noticed it for about a year and it has gotten larger. Pt states he previously had a lump removed from the same area, that was a benign cyst.

Surgical History (Reviewed 02/10/21)

History of excision of dermoid cyst pertinent history No pertinent past surgical history ROS Details: Gen. - denies fever or fatigue. Respiratory - denies shortness of breath. Cardiac - denies chest pain or palpitations. Skin - as per HPI. Exam Details: Alert awake oriented x3 Lungs-both lungs clear to auscultation CV-S1-S2 normal General Surgery Exam- Expanded Cyst/soft tissue swelling Cyst/soft tissue 1: Location: Left side of upper neck Size: Around 2 x 1 cm Description: No Drainage, No Fluctuation, Yes Overlying skin (Normal), Yes Mobility (Normal), No Redness and No Tenderness

Assessment & Plan L72.9 - Follicular cyst of the skin and subcutaneous tissue, unspecified Will schedule for excision of a skin cyst from left upper neck under local anesthesia. Patient was explained the details of procedure, its benefits and alternatives, risks associated with the procedure which included but not limited to bleeding, infection and wound dehiscence. Patient was explained that if final pathology came back as cancer then there would be a slight possibility of margins being positive for which he would require another procedure. Patient expressed good understanding of above-mentioned and asked appropriate questions which were answered to her satisfaction.

Coding Level of Care Code 99203 New Patient Level 3 Diagnoses Skin cyst L72.9

QUICK REVIEW

• ONLY office visit codes effected-99202-99215 • Deleted 99201 • Time is TOTAL time spent on the patient on the date of the encounter • Time is ranged instead of a typical time • Time based verbiage is a summary of activities now, vs. the prior “>50% etc” • This remains in place as requirement for all other portions of time based coding guidelines in the E&M section • Additional prolonged service codes to accommodate for time threshold being surpassed • MDM has been revised • History is no longer a scoring level measurement • Exam is no longer a scoring level measurement • MDM chart created for level guide resource • Straightforward • Low • Moderate • High • Three elements- you need 2 of 3 element requirements met to select level of MDM • “Number and Complexity of Problems Addressed” • “Amount and/or Complexity of Data to be Reviewed and Analyzed” • “Risk of Complications and/or Morbidity or Mortality of Patient Management” REFERENCES AND RESOURCES • https://namas.co/wp-content/uploads/2021/03/AMA-2021-E_M-Technical-Corrections-03092021.pdf– guidelines from AMA

• https://practice.asco.org/sites/default/files/drupalfiles/2020-12/NewProlongedEM%2012.2.20.pdf - additional information for prolonged service codes

• https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes- medicare-physician-fee-schedule-calendar-year-1 - information in regard to final rules and HCPCS code for prolonged services as well as inherent complexity code G2211.

• https://health.gov/healthypeople/objectives-and-data/social-determinants-health - social determinants of health

• https://namas13.wildapricot.org/resources/Documents/NAMAS%20EM%20Comparison%20Chart_Jan% 202020.pdf comparison chart for how the guidelines changed and quick look of each change and what remains important. REFERENCES AND RESOURCES • https://namas.co/ - information and examples found here.

• https://www.medcareadmin.com/bulletins/ A number of resources found at the link here from coding, to insurance policy, and E&M office visits information.

• https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf - revised MDM chart

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo – Information from CMS and the Medicare learning network has a wealth of information on specific topics and general sources as well.

AMA YouTube channel explains the following-these are from the symposium held in the beginning of the year and information has changed since however provide great insight as to the changes and their general reasons. https://www.youtube.com/watch?v=4WIGCVLK-u0 --MDM https://www.youtube.com/watch?v=FdyqEAvxt1k --Time https://www.youtube.com/watch?v=CfBASeFLagQ – What to expect

https://www.ama-assn.org/practice-management/cpt/implementing-cpt-evaluation-and-management-em-revisions AMA videos as above as well as a learning module to review and understand the changes straight from the source.

• Presenter contact information; [email protected]