Evaluation and Management Codes 2021 Update

Kayley JaquetManager of Regulatory Affairs

Jennifer Bash, RHIA, RCCIR, CIRCC, CPC, RCCDirector of Coding Education

DisclaimerThe information presented is based on the experience and interpretation of the presenters. Though all of the information has been carefully researched and checked for accuracy and completeness, ADVOCATE does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation.

CPT codes are trademark and copyright of the American Medical Association.

Resources• AMA• CMS• ACR

Agenda• Introduction• Historical background behind changes to E&M• Impact on reimbursement • Overview of E&M Guideline Changes• Practical Examples• Outline CPT code changes affecting radiology by modality

BackgroundBackground

Background- E&M CodesEvaluation of E&M codes has been an evolving issue since the late 80’s

• Concern: inequality between rates for procedural services (ex –surgery, invasive tests) and evaluation and management services

• Several organizations have been recommending adjustments on how e&m services are treated under the Medicare Physician Fee Schedule

• AMA, AMA RUC, MedPac – etc

• Utilization of E&M codes make up 40% of the MPFS• Office/Outpatient E&M codes make up 20%

Background- E&M Codes2019 MPFS – CMS proposes to reduce documentation burden for E&M services and blended payments

E&M Visit New Patients Established Patients

2018 Proposed - 2019 2018 Proposed - 2019

Level 1 $45 $44 $22 $24

Level 2 $76 $44 $45 $24

Level 3 $110 $44 $74 $24

Level 4 $167 $44 $109 $24

Level 5 $211 $135 $148 $93

Background- E&M Codes2020 MPFS – CMS accepts the RUC recommended RVU’s and reverses course on blended rates

• CMS decreased the number of levels for new patient (office or out patient) E&M visits to 4.

• Deletes Level 1 (99201) for new patients

• Established patient E&M visit levels remain at 5• CMS will pay at each level of service rather an utilize a blended rate

which was proposed/finalized in 2019 rule

Medicare Payment Formula

2020 Conversion Factor - $36.09

Final Conversion 2021 Factor - $32.40

2021 Impact to E&M RVUsE&M Code 2020 RVUs 2021 RVUs

New Patients

99201 0.48 Removed

99202 0.93 0.93

99203 1.42 1.60

99204 2.43 2.60

99205 3.17 3.50

Established Patients

99211 0.18 0.18

99212 0.48 0.70

99213 0.97 1.30

99214 1.50 1.92

99215 2.11 2.80

In addition to moving forward with E&M code changes, CMS proposed reevaluation of the following code sets:• End-Stage Renal Disease (ESRD) Monthly

Capitation Payment (MCP)Services • Transitional Care Management (TCM) Services• Maternity Services• Cognitive Impairment Assessment & Care

Planning• Initial Preventive Physical (IPPE) Examination &

Initial & Subsequent Annual Wellness (AWV) Visits

• Emergency Department Visits• Therapy Evaluations• Psychiatric Diagnostic Evaluations &

Psychotherapy Services

2021 - Impact by Specialty Specialty Impact

Nurse Anes. / Anes. Assistants -10%Radiology -10%Pathology -9%

Physical/Occupational Therapy -9%Cardiac Surgery -8%

Interventional Radiology -8%Anesthesiology -8%

Nuclear Medicine -8%General Surgery -6%

Radiation Oncology -5%Colon And Rectal Surgery -5%

Gastroenterology -4%Orthopedic Surgery -4%

Hand Surgery -3%Dermatology -1%

Podiatry -1%Clinical Psychologist 0%Physician Assistant 8%Allergy/Immunology 9%

Family Practice 13%Endocrinology 16%

Specialties that commonly bill E&M codes may see increases of up to 16%

Specialties that do not are expected to see decreases of up to -10%

FULL TABLE AVAILABLE IN 2021 FINAL RULE

PG 1661

Industry ResponseMany physician groups have been lobbying against these cuts since the initial proposal - COVID-19 now playing a role in what may happen.

• CMS is not able to suspend budget neutrality on their own• Congress would have to pass legislation to waive/suspend budget

neutrality

• H.R. 8505 – if passed, budget neutrality for the MPFS would be suspended for 1 year

• H.R. 8702 - Holding Providers Harmless from Medicare Cuts During COVID-19 Act – if passed, this legislation would stabilize Medicare payments for 2 years

Overview of E&M ChangesOverview of E&M Changes

CPT Revisions

• Revised CPT descriptions for office/outpatient visits• 99202-99205-New Patient• 99211-99215-Established Patient

• Code selection based on medical decision making (MDM) and TIME

CPT Descriptions-New Patient

CPT DESCRIPTION

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. When using time for code selection, 15-29 minutes of total time is spent on the date of the 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. When using time for code selection, 30-44 minutes of total time is spent on the date of the 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. When using time for code selection, 45-59 minutes of total time is spent on the date of the 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. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter

CPT Descriptions-Established Patient

CPT DESCRIPTION

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. When using time for code selection, 10-19 minutes of total time is spent on the date of the 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 level medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the 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 level medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the 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 level medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter

History & Examination

• “Medically appropriate” for the visit

• No longer REQUIRED

Time Component• Face to face encounter• “Total Time”

• Preparing to see the patient; • Ordering medication, tests, or procedures; • Referring with other healthcare professionals; • Care coordination; etc. *Must occur on the same day of the visit

99202 15-29 minutes 99212 10-19 minutes99203 30-44 minutes 99213 20-29 minutes99204 45-59 minutes 99214 30-39 minutes99205 60-74 minutes 99215 40-54 minutes

MDM Component• Medical Decision Making

• Straight forward• Low• Moderate• High

• Factors to consider:• Number and complexity of problem(s)• Amount and/or complexity of information that is

reviewed• Risk of complications, morbidity, and/or

mortality

Practical ExamplesExample #1: 70 year old new patient presents with low back pain for possible kyphoplasty. Medical decision making of moderatecomplexity. 50 minutes total time spent on the encounter.CPT: 99204

Example #2: 58 year old established patient presents with symptomatic varicose veins for EVLT evaluation. Medical decision making of low complexity. 25 minutes total time spent on the encounter.CPT: 99213

Example #3: 50 year old established patient presents for possible Y90 radioembolization. Medical decision making of moderatecomplexity. 35 minutes total time spent on the encounter.CPT: 99214

CPT Changes in RadiologyCPT Changes in Radiology

CT Lung Cancer Screening

CPT DESCRIPTION

71271 Computed tomography, thorax, low dose for lung cancer screening, without contrast material

Breast CT

CPT DESCRIPTION

0633T Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material

0634T Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s)

0635T Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s)

0636T Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s)

0637T Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s)

0638T Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s)

CATEGORY III CODES

Lung Biopsy

CPT DESCRIPTION

32408 Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed

Prostate Ablation

CPT DESCRIPTION

55880 Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance

Spinal Procedures

CPT DESCRIPTION

0627TPercutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level

0628T

Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; each additional level (List separately in addition to code for primary procedure)

0629TPercutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; each additional level (List separately in addition to code for primary procedure)

OTHER SPINAL PROCEDURE NOTES:• Category III codes for Magnetic Resonance Spectroscopy (MRS)

intervertebral disc (released 7/1/20)• Category III codes 0228-0231T for US guided transforaminal epidural

injection have been DELETED

Final Notes

• Final Rule• CMS Fact Sheet• Full Text

• NCCI Policy Manual

Q&A

Thank you!Jennifer Bash- jennifer.bash@advocatercm.comKayley Jaquet- kayley.jaquet@advocatercm.com