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2021 EM – Prolonged Services

In this blog series we are going to do a deep dive into the 2021 E/M Changes. During the series I will be referring to the official guidelines from the AMA. Click the link below to download a copy.

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

In the last post we talked about how time is going to change the way you level your office/outpatient visits come 2021. Today we are going to dig into how prolonged services will change as well.

New Prolonged Service Code

If you want an early Christmas present click on the link above and go to page 9. Starting from page 9 until the end of the document is a preview of of the 2021 CPT-4 code book. If you are as big of a coding geek as I am you will be able to imagine how much my dorky coder heart swooned when I saw an actual preview of the 2021 CPT book in this document. But I digress. If you will refer to the last two pages, you will see that the AMA has created a brand new CPT code to report prolonged service codes. That code is 99XXX. Yep weird huh? Below are some guidance on how you will use 99XXX in 2021.

Report 99XXX with 99205 and 99215 only.

The guidance in the parenthesis tells us that we can only report 99XXX with EM codes 99205 and 99215. Do not report 99XXX with any other codes.

Do Not Report 99XXX for Less Than 15 Minutes

The guidance in parenthesis also instructs us to not report prolonged services for less than 15 mins. In those cases report only 99205 or 99215.

Prolonged Service Time Table

The AMA created the handy table below to make it easy to report office/outpatient prolonged services.

AMA CPT 2021

I would like to point out a bonus Christmas present. Notice on the table it states that if you document 75-89 minutes for a new patient you can report 99205 with 99XXX x 1 unit. Well that is very interesting since the time range (see table below) for 99205 will be 60-74 minutes. Let that sink in. The AMA is saying that if you 75 minutes with a new patient you can bill 99205 and also 1 unit of 99XXX. That is literally only one minute more than the time range for the code 60-74 minutes. You are welcome! Note that the same is true with established patient visits. If you document 55 minutes with an established patient you get to bill 99215 plus 99XXX x 1.

CPT-4 CodeTime Range
9920560-74
9921540-54

Before you celebrate too much let’s ask the most important question. Will CMS follow suit with their time calculations? Don’t bet on it. According to the CMS Proposed rule that was released on 8/17/2020 they are not going to be following the AMA’s lead on this. If you compare the CMS tables below to the AMA tables at the beginning of this post you will see there is a difference in the way the CMS sees the threshold times for 99XXX. Notice that for 99205 x 1 unit of 99XXX the time is 75-89 minutes for the AMA but it is 89-103 minutes for CMS. Since this is the “proposed rule” it is subject to change. Once the final rule comes out in November we will know for sure.

CMS Proposed Rule https://www.govinfo.gov/content/pkg/FR-2020-08-17/pdf/2020-17127.pdf
CMS Propose Rule https://www.govinfo.gov/content/pkg/FR-2020-08-17/pdf/2020-17127.pdf

The next post will be all about medical decision making (MDM). We will talk about how it is changing for 2021 and how it will be used to level an office visit in 2021.

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2021 EM Changes – Time

In this blog series we are going to do a deep dive into the 2021 E/M Changes. During the series I will be referring to the official guidelines from the AMA. Click the link below to download a copy.

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

In today’s post I am going to address how time will be used to level services in 2021.

Counseling and/or Coordination of Care Caveat Goes Away

Currently, you have to document that you spent greater than 50% of your visit in counseling and/or coordination of care in order to level your office service based on time. The 2021 changes will allow you to report codes 99202-99215 based on the total time spent regardless of counseling or coordination of care.

“Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service.”

AMA

Activities You Can Count Towards Your Time

You are going to be pleasantly surprised when you see what activities you will be able to count toward your total time. Keep in mind though that the time for these activities only count if they are performed on the date of the service. You cannot count time spent prior to or after a visit. To properly document your time you need to document the total time spent and then detail the activities that you performed for the visit.

  • Preparing to see the patient (ie, reviewing tests)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate exam
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, test, or procedures
  • Referring and communicating with other health care providers
  • Documenting clinical information in the EHR or medical record
  • Independently interpreting result (not separately reported)
  • Communicating results to patient/family/caregiver
  • Care coordination (not separately reported)

Do Not Count Time Spent on Separately Reported Activities

You may have noticed that they keep mentioning (not separately reported). What they mean is if you are going to bill it separately do not count the time for that as EM time. For example, if you do an EKG on a patient and bill for it, do not also count the time it took you to do the EKG as part of your EM. Don’t double dip. It is as simple as that.

Time Thresholds Change in 2021

Now let’s take a peak at how the time thresholds will look in 2021.

CPT CodeCurrent Time2021 Time
9920110deleted
992022015-29
992033030-44
992044545-59
992056060-75
992121010-19
992131520-29
992142530-39
992154040-54

In the next blog post we will discuss how these time changes will affect prolonged services.

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2021 EM – Introduction

In this blog series we are going to do a deep dive into the 2021 E/M Changes. During the series I will be referring to the official guidelines from the AMA. Click the link below to download a copy.

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

In today’s post I am going to address two common misconceptions about the changes.

MYTH ONE – All EM Codes Are Changing

This is not true. The 2021 E/M changes only affect the office visit codes 99201-99215 and prolonged services codes 99354, 99355, 99356, 99XXX. Don’t worry we are going to explain that crazy 99XXX code in a later blog post.

MYTH TWO – Providers will no longer have to document history or exam.

You may have heard that you will no longer have to document a history or exam. This is not true. The guidelines do not say this at all. Instead, they empower you to perform and document histories and exams that you feel are relevant patient’s care.  The exciting news is you will not use history or exam to level your service. Finally, you will have freedom from those pesky bullets.

Another interesting change is that code 99201 will go away. This was a small but brilliant move on the part of the AMA. It allows the levels to line up perfectly based on MDM. In 2021 an office level 2 will always be straightforward MDM and an office level 5 will always high MDM. Let me illustrate this for you.

Notice that currently we have two straightforward new patient office visits. The difference between these two comes down to history and exam. But since history and exam will no longer be used to determine your level of service, we no longer need a 99201.

NEW OFFICE VISIT CODING
New PtMDM LevelEst PtMDM Level
99201Straightforward99211Nurse visit
99202Straightforward99212Straightforward
99203Low99213Low
99204Moderate99214Moderate
99205High99215High
2021 OFFICE VISIT CODING
New PtMDM LevelEst PtMDM Level
99202Straightforward99212Straightforward
99203Low99213Low
99204Moderate99214Moderate
99205High99215High

In the next post we will dig deep into how time will be used to determine your level of service. I think you will like how time is going to be on your side in 2021.

Angie the Coder (Angela Wood, CPC) has over 25 years of experience in physician compliance, education and reimbursement optimization.

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Are you losing money with Medicare reimbursement?

Let me show you how you may be losing money with Medicare reimbursement!

What if I told you that one small element of history could be costing you thousands of dollars in Medicare reimbursement?

Let me illustrate. Most likely, when you are reporting an initial hospital admission you are seeing a patient who is either moderate or high complexity MDM (medical decision making). Both moderate and high MDM require a comprehensive history and a comprehensive exam. In many of the inpatient admissions I audit, I see providers documenting all the necessary history and exam elements except for the family history. Missing this one simple element downgrades the history from comprehensive to detailed.  If you have a coder checking your levels, he or she is probably catching this and changing the code to 99221. If so, you are losing money each time you document this way. If not, you are probably overbilling Medicare each time.  Neither of these options are good.

I have included the 2020 Medicare National Fees below to compare the Medicare reimbursement for these three codes below:

CPT
CODE		HISTORYEXAMDECISION MAKING LEVELMEDICARE NATIONAL FEE
99221DETAILEDDETAILEDLOW$103.94
99222COMPCOMPMODERATE$140.39
99223COMPCOMPHIGH$206.07

Notice that If you are admitting a high MDM patient, there is a difference of $102.13 from 99223 to 99221!  If you have to be down-coded from 99223 to 99221 only once a month that is a potential loss of $1,225.56 a year. What if you are doing this once a week? That is a potential loss of $5,310.76 a year.  

CPT
CODE		HISTORYEXAMDECISION MAKING LEVELMEDICARE NATIONAL FEE
99221DETAILEDDETAILEDLOW$103.94
99223COMPCOMPHIGH$206.07
Loss$102.13
once a month$1,225.56
once a week$5,310.76

Remember I mentioned that the moderate MDM code 99222 also requires a family history? If you are also making this mistake with your moderate MDM admissions as well you are losing $36.45 each time.  That is a $437.40 loss if you only do it about once a month and $1895.40 if you are doing it once a week.

CPT
CODE		HISTORYEXAMDECISION MAKING LEVELMEDICARE NATIONAL FEE
99221DETAILEDDETAILEDLOW$103.94
99222COMPCOMPMODERATE$140.39
Loss$36.45
once a month$437.40
once a week$1,895.40

The good news is that this is an easy fix. Get in the habit of performing and documenting a family history on when admitting a patient with moderate to high MDM. For example, if you are admitting a patient for chest pain, review the family history of cardiac disease. Then document something as simple as this “father with CAD, no other family hx of CV disease”.  Or you can review and refer to another provider’s family history. For example, reviewed Dr. Smith’s family hx from earlier today with patient no changes noted.” If the patient is unable to give a history, you simply document something like this, “unable to obtain HPI, ROS, PFSH due to severe dementia and no other source of history available.” Avoid using the phrases “family history non-contributory”, “family history negative”, and “family history unremarkable” as Medicare has already deemed these statements are not acceptable.

As you can see it only takes a small change to make a big difference.


Angie the Coder (Angela Wood, CPC) has over 25 years of experience in physician compliance, education and reimbursement optimization.