Per CMS: they have “established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience. In carrying out this internal process CMS is moving the needle and removing regulatory obstacles that get in the way of providers spending time with patients.”
With the new changes code 99201 will be deleted for redundancy of medical decision making. The new E/M code descriptions are as follows:
New patient:
99202 – Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 15-29 minutes total time on date of encounter.
99203 – Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low medical decision making. 30-44 minutes total time on date of encounter.
99204 – Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate medical decision making. 45-59 minutes total time on date of encounter.
99205 – Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high medical decision making. 60-74 minutes total time on date of encounter.
Established patient:
99211 – Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other QHCP, Usually the presenting problem(s) are minimal. No time associated. (99211 will be used if clinical staff members perform the face-to-face visit under the supervision of the physician or other qualified healthcare professional)
99212 – Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 10-19 minutes total time on date of encounter.
99213 – Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low medical decision making. 20-29 minutes total time on date of encounter.
99214 – Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate medical decision making. 30-39 minutes total time on date of encounter.
99215 – Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high medical decision making. 40-54 minutes total time on date of encounter.
Time
For codes 99202-99215 the definition of time will mean “total time spent on the day of the encounter”. CMS will still count only face-to-face and non-face-to-face time by the reporting practitioner on the day the patient is seen. CMS will be eliminating its requirement that physicians must spend at least 50% of the face time on counseling or coordination of care. CMS will allow providers to select an E/M level based on total time spent for the encounter. These definitions only apply when code selection is primarily based on time, not medical decision making.
The activities included in time are:
- Preparing to see the patient (review of testing, consults, etc)
- 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, procedures
- Referring and communication 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)
Prolonged Services
When a visit exceeds the threshold for 99205 or 99215 additional time can be reported utilizing the prolonged service codes +99XXX. The code’s description reads:
Prolonged office or other outpatient evaluation and management service(s) (beyond the total 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 (List separately in addition to codes 99205, 99215 for office or other outpatient E/M services).
- Code +99XXX will apply only if the primary E/M code is chosen based on time
- The new code will include total time with and without direct patient contact on the date of service. Remember that 99202-99215 also will use total time rather than intraservice time starting in 2021
- +99XXX will be used once for each 15 minutes beyond the primary service time
- The appropriate primary codes will only be 99205, which represents the longest time among the new patient codes, and 99215, which represents the longest time among the established patient codes
- New guidelines that will accompany +99XXX provide the rule that the code should not be reported for any time period less than 15 minutes. For example, 99205 will represent 60-74 minutes in 2021. To report 75-89 minutes, 99205 will be reported along with +99XXX. If the total time reaches 90-104 minutes, 99205 will be reported alongside two units of +99XXX.
Split/Shared Services
When time is being used to select the level of service for which time-based reporting of split/shared services is allowed, the time personally spent by the physician and other qualified healthcare professional assessing and managing the patient on the date of encounter is added up to define the total time. Only distinct time should be summed up for split/shared services. Any time that the providers spend together to meet with or discuss the patient should be counted only once, as if you’re counting the time of one individual. Activities that qualify for time-based reporting include “day of” activities such as preparation for the visit, reviewing tests, performance of medically appropriate examination or evaluation and orders for medications, tests, or procedures. Time spent performing other billable services cannot count toward time to support the E/M service – this would be considered double-dipping. An example would be if care coordination is reported using a separate CPT code it should not be included in the total time for the E/M service.
