2021 Documentation and Coding for Outpatient Evaluation and Management Services

On December 1, the Centers for Medicare & Medicaid Services (CMS) released the 2021 Physician Fee Schedule (PFS) final rule that includes changes to evaluation and management codes effective January 1, 2021. Practices, physicians, and staff must be aware of the modifications to ensure a successful transition and avoid any disruption in reimbursement.

Documentation

Under this new framework, history and exam will no longer be used to select the code level for office visits. The selection of code level will be based on either the level of Medical Decision Making (MDM) or the total time personally spent by the reporting practitioner on the day of the visit (including face-to-face and non-face-to-face). Under the new CPT coding framework, the history and exam components will only be documented when medically appropriate.

Medical decision-making elements.

The medical decision-making elements associated with codes 99202-99215 will consist of three components: 1) The number and complexity of problems addressed 2) Amount and/or complexity of data to be reviewed and analyzed AND 3) Risk of complications and/or morbidity or mortality of patient management. In order to select a level of E&M service, two of the three elements must be met or exceeded. A new medical decision-making table further outlines the criteria for the E&M code level selection.

Payment

Beginning in 2021, CPT code 99201 will be eliminated. Just like in 2020, there will continue to be four levels for new patients (levels 2 through 5) and five levels for established patients (levels 1 through 5). CMS is also moving forward with payment increases for most office visits. 

G2211

In its 2020 final rule, CMS finalized separate payment for HCPCS code GPC1X, to provide payment for visit complexity inherent to E/M associated with medical care services that serve as the continuing focal point for all needed healthcare services. In its 2021 final rule, CMS replaced HCPCS code GPC1X with HCPCS code G2211 and confirmed it can be reported for both new and established patients.

In terms of documentation, CMS states that it expects that information included in the medical record or in the claims history for a patient could serve as support documentation. Examples could include diagnoses, the practitioner’s assessment and plan for the visit, and/or other service codes billed.

G2212

In its 2020 final rule, CMS finalized CPT code 99417 to report prolonged office visits when time is used for code level selection and the time for a level 5 office visit is exceeded by 15 minutes or more. CMS believes that allowing reporting of CPT 99417 after only the minimum time for the level 5 visit is exceeded by at least 15 minutes would result in double counting time. This differs from the AMA CPT Editorial Panel’s interpretation of the code. 

Therefore, CMS finalized the creation of HCPCS code G2212, which could be reported when the maximum time for the level 5 visit is exceeded by at least 15 minutes on the date of service. The valuation for HCPCS code G2212 will be the same as for CPT code 99417.

 

Summary of Codes and Work RVUs Finalized in the PFS Final Rule for CY 2021
HCPCS Code	2020 wRVU	2021 wRVU
99201	0.48	N/A
99202	0.93	0.93
99203	1.42	1.6
99204	2.43	2.6
99205	3.17	3.5
99211	0.18	0.18
99212	0.48	0.7
99213	0.97	1.3
99214	1.5	1.92
99215	2.11	2.8
G2212	N/A	0.61
G2211	N/A	0.33

 

E/M Comparable Visits

CMS finalized its proposal to revalue a group of code sets that include or rely upon office visit valuation. These code sets include end-stage renal disease (ESRD) monthly capitation payment (MCP) services, transitional care management (TCM) services, maternity services, cognitive impairment assessment and care planning, initial preventive physical examination (IPPE), initial and subsequent annual wellness visits (AWV), emergency department visits, therapy evaluation services, and psychiatric diagnostic evaluation services.

Summary

While the new E/M coding guidelines should decrease unnecessary documentation and streamline requirements, the payment increases associated with office visits contribute to a 10.2% decrease to the conversion factor. This decrease will result in many specialties seeing reimbursement cuts during a time when COVID-19 cases are increasing and practices are scrambling to remain financially viable. In a press release, CMS put a positive spin on the decrease, saying they are “prioritizing CMS' investment in primary care and chronic disease management by increasing payments to physicians and other practitioners for the additional time they spend with patients, especially those with chronic conditions." Finally, the fact that the add-on codes are G codes will create challenges to practices utilizing them because it is uncertain whether commercial plans will immediately adopt them.