Several ICD-10 and CPT code changes came into effect for urology in 2020. Practitioners need to understand the updates and associated urology medical billing guidelines to ensure accurate reporting and timely reimbursement.
New ICD-10 Codes
Diagnosis codes must always be assigned to the highest known level of specificity. Effective Oct 1, 2019, ICD-10 code changes for primary urologic issues include:
code description changes
codes additions, and
a new instructional note without description change
The following table from a Urology Times article shows the 2020 ICD-10 codes changes for primary urologic concerns:
CPT Code Changes
New Series of Category III Codes
CPT codes include Category I codes and Category III (T codes) codes. While Cat I codes are the standard codes used to report services, Cat III codes”) are used to track the utilization of emerging technologies, services, and procedures.
In 2020, a new series of category III codes 0587T-0590T for insertion, replacement, or removal integrated single device neurostimulation system and the analysis and testing came into effect on Jan 1, 2020. The new codes have been added to account for the differences necessary to perform these services(www.community.auanet.org):
0582T – Transurethral ablation of malignant prostate tissue by high-energy water vapor thermotherapy, including intraoperative imaging and needle guidance
05871– Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming and eimaging guidance when performed, posterior tibial nerve
0588T – Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
0589T – Electronic analysis with simple programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 1-3 parameters
0590T – Electronic analysis with complex programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 4 or more parameters
Points to Note
A recent Urology Times article cautions that since Category III codes are a unique subset of the CPT code set, urologists and practices need to understand their value, when to use them, and when they can be used for reimbursement.
As the code descriptors of the codes include imaging, programming, and analysis a as part of the placement procedure, these services are not separately reported.
There are separate codes to report electronic analysis with simple (0589T) and complex (0590T) programming. These codes should be used when programming services are performed independent of placement and revision/removal services.
The exclusionary parenthetical that follows each code and other parentheticals within the Category III section for these codes and in other section of the code set provide guidance regarding the intended use for the new codes.
New and Deleted Codes for Biofeedback Training
New – Two new time-based codes have been created so as to allow the physician to “most accurately describe and be reimbursed for the amount of time and effort spent face to face with an individual patient” (www.urology.com). The two new time-based biofeedback codes are:
90912 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient.
90913 . . . each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)
Points to Note:
Codes 90912 and 90913 include EMG and/or manometry is included, when performed.
Code 90913 is an add-on code to “describe each additional 15 minutes” of one-on-one physician or other qualified health care professional contact with the patient. Code 90913 must be used in conjunction with code 90912 and cannot be billed alone.
Deleted – The following code has been deleted:
90911 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
The 2020 CPT code changes for urology include revisions under urinary system/bladder introduction:
The parenthetical note following code 51715 (Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck) has been deleted
The descriptor of Orchiopexy code 54640 has been revised to:
CPT 54640 – Orchiopexy, inguinal or scrotal approach
Urology practices need to update templates to load the new codes. When it comes to billing Category III codes, they must check payer rules before providing the service to determine how move forward. Medical billing companies that specialize in urology medical billing stay up to date on ICD-10 and CPT code changes. Partnering with a reliable service provider is the best way report the right codes for services rendered.
New, revised and deleted codes come into effect each year on January 1. Outsourcing companies providing billing and medical coding services review the updates carefully to ensure that the physician practices they serve make the necessary changes to their resources and protocols for accurate claim submission.
In Calendar Year 2020, otolaryngology practices are dealing with important changes to endoscopic sinus billing and coding, which include changes to CPT code descriptors and application of the special rule for multiple endoscopic procedures.
About Nasal Endoscopy
Nasal endoscopy is a common procedure performed in the otolaryngologist’s office. It involves using an endoscope to view the nasal and sinus passages. A nasal endoscope consists of a thin, flexible tube with a tiny video camera and a light. The instrument projects magnified images onto a screen. The minimally-invasive nasal endoscopy procedure helps in the diagnosis and treatment of the following health conditions:
Nasal and sinus infection (rhinosinusitis)
Loss of ability to smell
Cerebrospinal fluid leak
Nasal endoscopy allows the physician to obtain details about problems, such as bleeding and swelling of the nasal tissues or a growth, which direct visualization cannot provide. It can be used to remove a foreign object from the nose or to assess the progress of treatments for sinus and nasal problems.
If there is a blockage, sinus surgery can remove the obstruction, open the sinuses, and restore natural drainage. Endoscopic sinus surgery is clinically indicated for patients with chronic sinusitis, or other conditions, such as nasal tumors and nasal polyps. In some cases, small instruments may be used to remove tiny samples of tissue or perform other tasks.
Nasal Endoscopy Billing and Coding Changes
Revised nasal/sinus endoscopy CPT code descriptors: The descriptors of several nasal/sinus endoscopy codes have been revised for 2020. The codes are now arranged into more specific families (www.medtronsoftware.com):
31292 Nasal/sinus endoscopy, surgical, with orbital decompression; medial or inferior wall (Do not report 31292 in conjuction with 31237, 31253, 31254, 31255, 31257, 31259, 31293, 31296, when performed on the ipsilateral side)
31293 Nasal/sinus endoscopy, surgical, with orbital decompression; medial and inferior wall (Do not report 31293 in conjuction with 31237, 31253, 31254, 31255, 31257, 31259, 31292, when performed on the ipsilateral side)
31295 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa (Do not report 31295 in conjuction with 31233, 31256, 31267, when performed on the ipsilateral side)
31296 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium (Do not report 31296 in conjunction with 31253, 31276, 31297, 31298, when performed on the ipsilateral side)
31297 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); sphenoid sinus ostium (Do not report 31297 in conjunction with 31235, 31257, 31259, 31287, 31288, 31296, 31298, when performed on the ipsilateral side)
31298 Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia (Do not report 31298 in conjunction with 31235, 31253, 31257, 31259, 31276, 31287, 31288, 31296, 31297, when performed on the ipsilateral side)
There is also a new Category III code: 0583T Tympanostomy (requiring insertion of ventilating tube), using an automated tube delivery system, iontophoresis local anesthesia
Special rules for multiple endoscopic procedures: CMS has made the special rule for multiple endoscopic procedures applicable for procedures represented by nasal sinus medical codes 31231-31298.
The key points to note are as follows:
CPT 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure), is the base code for this family of endoscopic surgeries. This base code is considered integral to the other endoscopic sinus surgeries. It is never paid separately when performed with other endoscopic services in the family.
Code 31231 is cannot be reported with more extensive nasal endoscopies unless the more extensive nasal endoscopies are performed on different sites/structures/locations. Modifier 59 or modifier XS would still be used with 31231 under the multiple endoscopy rules.
If two or more sinus endoscopies in the same family are performed that do not include the base code 31231, each may be reported.
In 2018, four new Nasal Sinus Endoscopy codes (31241, 31253, 31257, 31259, and 31298) were introduced. Each code describes bundles of services frequently performed together. AAPC cautions: “The multiple endoscopy rule does not give license to unbundle these scope codes.”
With the multiple scope rule, otolaryngologists will get be reimbursed 100 percent for the highest valued procedure. The other nasal endoscopy codes will be paid at their value minus the value of the base code, 31231.
Billing bilateral procedures: In response to a commentator request, CMS also clarified that a multiple nasal endoscopy procedure that is performed bilaterally will be multiplied by 150 percent and then the fee for the base nasal procedure, 31231, will be subtracted (www.aapc.com).
Proper Documentation is Critical to Prevent Claim Denials
A special study of Medicare Part B claims for diagnostic nasal endoscopy submitted between April and June 2014 found that insufficient documentation was the most common reason for most improper payments, according to an AAPC article. To reduce risks of denial, providers must meet the documentation requirements of Medicare administrative contractors.
Four essential elements that must be documented in the medical record are:
The correct date of service
The reason for the procedure
The results of the procedure
The physician or other qualified healthcare professional’s signature (and/or signature log, or attestation)
With accurate and complete clinical documentation, medical billing and coding companies can connect services provided with the right nasal endoscopy billing codes for appropriate reimbursement.
As a holistic therapy for various musculoskeletal conditions, the demand for chiropractic care is growing. Chiropractors use a range of manipulative techniques to reduce pain, improve function and enhance mobility in the body. However, there are very specific codes and billing rules to report these specialized services. Using the services of a chiropractic medical billing expert is recommended to convey the right message to payers, avoid audits, and maximize revenue. An experienced medical billing company would be knowledgeable about how to ensure chiropractic billing, coding, and compliance with the most current guidelines. In fact, in 2020, chiropractic practices need to be ready for certain coding changes.
Chiropractic CPT Code Changes for 2020
According to findacode.com, the CPT code changes impacting chiropractors that will take effect January 1, 2020, are as follows:
Code 90911 replaced with two new codes: Currently, there are two pure biofeedback codes, 90901 and 90911. Code 90901 Biofeedback training by any modality will remain unchanged. Code 90911 Pelvic floor training for the treatment of incontinence has been deleted and replaced with two new codes, which also have changes to official reporting guidelines.
Two new codes to report dry needling: The AMA CPT Editorial Panel approved two new CPT codes to report dry needling of musculature trigger points in 2020. The new codes are:
205X1, needle insertion without injection, 1 or 2 muscles.
205X2, needle insertion without injection, 3 or more muscles
The AMA has also added new guidelines for code 97140 Manual therapy techniques, e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction, 1 or more regions) and acupuncture codes (97810-97814) to use the new codes for “dry needling or trigger point acupuncture.
Nine new codes and guideline changes for Health and Behavior Assessment/Intervention: The following health and behavior assessment codes have been replaced with nine new codes, along with major changes to guidelines:
96150 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment
96151 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment
96152 Health and behavior intervention, each 15 minutes, face-to-face; individual
The new codes break out the services into individual, group, and family services, and include time based reporting with add-on codes as well as definitions of both an assessment and an intervention.
New Category III codes for Health and Well-being Coaching: The American Medical Association notes: “Health and well-being coaching is a patient-centered approach wherein patients determine their goals, use self-discovery or active learning processes together with content education to work toward their goals, and self-monitor behaviors to increase accountability, all within the context of an interpersonal relationship with a coach”.
New category III codes have been introduced for specially-trained non physicians to help a patient achieve better health:
0591T Health and Well-Being Coaching face-to-face; individual, initial assessment
0592T individual, follow-up session, at least 30 minutes
0593T group (two or more individuals), at least 30 minutes
These services cannot be reported with the Health and Behavior Assessment/Intervention codes.
Muscle testing procedure codes deleted: The CPT codes 95831-95834 that identify manual muscle testing procedures have been deleted. CPT guidelines recommend using 97161-97172 Evaluation and re-evaluation of a patient by a physical therapist, occupational therapist, and athletic trainer,instead. There is no change in the range of motion codes.
Online evaluation codes replaced: Codes online medical evaluations 99444 (for physicians) and 98969 (for nonphysicians) have been replaced for 2020. The new codes and their associated guidelines include exclusions as to when these codes can and cannot be used.
According to www.find-a-code.com, the biggest issue that providers will need to avoid is the potential for over-reporting or “double dipping”. For e.g., if there is an E/M visit within 7 days before or after an online evaluation, these codes cannot be reported separately because the service is considered part of the E/M service. Reporting them separately would be considered “double dipping”.
The year 2020 will not bring any significant changes to the ICD-10 codes that chiropractors frequently use. However, one noteworthy change is the addition of a new guideline for growth plate fractures in Section 19.c of the Official ICD-10-CM Coding Guidelines:
3) Physeal fractures: For physeal fractures, assign only the code identifying the type of physeal fracture. Do not assign a separate code to identify the specific bone that is fractured.
Expert Medical Billing Services to File Correct Claims
Chiropractic medical billing is different from billing for other specialties, and often, much more challenging. Medical billing outsourcing companies that specialize in chiropractic medical billing and coding keep track of coding updates and reporting guidelines. They can help providers file correct claims to boost revenue and get paid sooner.
The American Medical Association’s (AMA’s) 2020 update of the CPT code set comprises 394 code changes, including 248 new codes, 71 deletions, and 75 revisions. A thorough understanding of these changes is important for correct coding and reimbursement for the services represented by these codes. Coders in reliable medical billing and coding companies stay up-to-date on annual code changes and are well-positioned to help physicians report services and procedures correctly.
The 2020 CPT code changes, which come into effect on January 1, were made based on broad input from physicians, medical specialty societies and the greater health care community. Here are the highlights and implications of the updates:
6 new CPT codes to report e-visits: Electronic visits (e-visits) help patients who would otherwise find it difficult to pay for medical care or have to travel long distances. Digital health tools address this concern by allowing patients and physicians to communicate asynchronously and outside of office settings. In 2020, there are 6 new CPT codes for reporting a range of digital health services including e-visits through secure patient portal messages.
99421, 99422 and 99423 describe patient-initiated digital communications with a physician or other qualified health professional
98970, 98971 and 98972 represent patient-initiated digital communications with a nonphysician health professional
2 new codes for home blood-pressure monitoring: Also spurred by the popularity of digital health tools, new codes 99473 and 99474 will allow reporting self-measured blood pressure monitoring. Tracking blood pressure at home helps patients take an active role in the process and enables physicians to better diagnose and treat hypertension.
Commenting on the new codes for digital health services, AMA President Patrice A. Harris, MD, MA said, “With the advance of new technologies for e-visits and health monitoring, many patients are realizing the best access point for physician care is once again their home….The new CPT codes will promote the integration of these home-based services that can be a significant part of a digital solution for expanding access to health care, preventing and managing chronic disease, and overcoming geographic and socioeconomic barriers to care.”
Updates for health and behavior assessment and intervention services: New codes 96156, 96158, 96164, 96167, and 96170, and add-on codes 96159, 96165, 96168, and 96171 for health and behavior assessment and intervention services will replace six older codes. According to the AMA, this update is intended to “more accurately reflect current clinical practice that increasingly emphasizes interdisciplinary care coordination and teamwork with physicians in primary care and specialty settings.”
Significant enhancements for reporting long-term electroencephalographic (EEG) monitoring services (95700-95726):Monitoring the electrical activity of the brain is critical to diagnose epilepsy. Four older codes have been deleted to make way for 23 new codes for long-term electroencephalographic (EEG) monitoring services. According to the AMA, the new codes provide better clarity around the services reported by a technologist, a physician, or another qualified health care provider.
Other approved CPT changes for 2020 according to a March 2019 AAPC article include:
A new code to report a quadrivalent inactivated-adjuvanted influenza virus vaccine
Deletion of cardiac device evaluation code 93299 Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system or subcutaneous cardiac rhythm monitor system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results
A new category III code to report an assay of cancer stem cell
Two new category III codes to report autologous cellular implant
A new category III code to report evacuation of meibomian glands
Addition of two category III codes to report transcervical bilateral permanent fallopian tube occlusion and the separate introduction of saline for confirmation of occlusion via sonosalpingingraphy
Deletion of codes 21296 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach and 43401 Transection of esophagus with repair, for esophageal varices due to low utilization
Companies that provide coding and medical billing services review the changes to codes as well as reporting instructions as they are announced. With legible, complete and accurate clinical documentation, expert AAPC-certified coders can help physicians report the correct codes and ensure proper reimbursement for their services.
Physicians need to know and understand diagnosis codes to ensure proper reimbursement for claims. Practices and providers of coding and medical billing services are ready to implement the ICD-10 code updates that will come into effect in fiscal year 2020. These codes are for use from October 1, 2019 through September 30, 2020. These updates include 273 new codes, 21 deleted codes, and 30 code title revisions.
According to the American Health Information Management Association (AHIMA), there are 72,184 ICD-10-CM codes for fiscal year 2020 compared to 71,932 for fiscal year 2019.
Diseases of the circulatory system: There are 30 new codes in the chapter Diseases of the circulatory system (I00-I99). These changes include four five-character options for atrial fibrillation:
Eight new codes have been added to subcategory I80.2, Phlebitis and thrombophlebitis of other and unspecified deep vessels of lower extremities, to identify thrombophlebitis or thrombosis involving the peroneal vein or muscular branch veins. The new 2020 codes under category I80 Phlebitis and thrombophlebitis for specific vein thrombosis in the distal lower limb allow better capture these diagnoses and avoid current limitations with capturing patient safety-related events, according to the Agency for Healthcare Research and Quality (AHRQ). Code options include:
I80.24- (Phlebitis and thrombophlebitis of peroneal vein)
I80.25- (Phlebitis and thrombophlebitis of calf muscular vein)
I82.45- (Acute embolism and thrombosis of peroneal vein)
I82.46- (Acute embolism and thrombosis of calf muscular vein)
I82.55- (Chronic embolism and thrombosis of peroneal vein)
I82.56- (Chronic embolism and thrombosis of calf muscular vein).
Category L89 Pressure ulcer: There are new ICD-10 codes for pressure ulcers. Deep tissue injury” is indexed to Ulcer, pressure, unstageable, and then by site. AHRQ noted that “unstageable ulcers can ONLY be Stage 3 or 4 by definition (‘full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.’). By contrast, deep tissue injury may resolve without tissue loss. In addition, deep tissue injuries often have a combined etiology involving both ischemia and pressure.” Based on AHRQ’s request, several new codes for deep pressure-induced tissue damage go into effect Oct. 1, 2019, which will change ICD coding for pressure ulcers and non-pressure ulcers.
Combined immunodeficiencies D81: There are new codes under category D81 Combined immunodeficiencies to differentiate between the types of adenosine deaminase deficiency:
Adenosine deaminase deficiency, unspecified
Severe combined immunodeficiency due to adenosine deaminase deficiency
Adenosine deaminase 2 deficiency
Other adenosine deaminase deficiency
These changes allow Type 2 which generally involves mild immunodeficiencies to be differentiated from Type 1 which causes severe combined immunodeficiency (SCID).
Breast Lump in Overlapping Quadrants: The American College of Obstetricians and Gynecologists (ACOG) reviewed and supported new codes that align the structure with the current codes for malignant neoplasm of breast (subcategory C50.8). New codes N63.15 Unspecified lump in the right breast, overlapping quadrants and N63.25 Unspecified lump in the left breast, overlapping quadrants allow for proper code assignment when an unspecified lump in the breast overlaps anatomic sites classifiable to different codes.
Factors Influencing Health Status and Contact with Health Services (Z00-Z99): There are 13 new codes in Chapter 21 Factors Influencing Health Status and Contact with Health Services (Z00-Z99), which will impact anesthesiology medical billing. ICD-10 2020 changes the inclusion terms for the sub-category Z45.42 as well as the title of this sub-category. The title of the sub-category from (Encounter for Adjustment and Management of Neuropacemaker (brain) (peripheral nerve) (spinal cord)) has changed to (Encounter for Adjustment and Management of Implanted Nervous System Device). The American Academy of Pain Medicine notes the addition of the following inclusion terms to the sub-category:
Encounter for adjustment and management of brain neurostimulator
Encounter for adjustment and management of gastric neurostimulator
Encounter for adjustment and management of peripheral nerve neurostimulator
Encounter for adjustment and management of sacral nerve neurostimulator
Encounter for adjustment and management of spinal cord neurostimulator
Encounter for adjustment and management of vagus nerve neurostimulator
A recent AAPC article also lists the following ICD-10 changes for FY 2020:
Cyclical Vomiting Syndrome: Beginning Oct. 1, 2019, there is new code R11.15 Cyclical vomiting syndrome unrelated to migraine to represent the clinical significance of cyclical vomiting syndrome and the treatment of the disorder not related to migraines. Codes under G43 Migraine and R11 Nausea and vomiting have been revised to accommodate R11.15.
Ehlers-Danlos Syndrome (EDS): Code Q79.6 Ehlers-Danlos syndrome has been revised and expanded to include codes for the various types of this heritable connective tissue disorder. Vascular EDS, the most severe EDS type, are associated with early mortality.
Latent Tuberculosis Infection (LTBI): LTBI is a condition in which a person is infected with the TB bacteria but does not have signs of active TB disease and does not feel ill (World Health Organization). To distinguish between latent and active TB, ICD-10 2020 has added new codes under categories Z11 Encounter for screening for infectious and parasitic diseases, Z22 Carrier of infectious disease, and Z86 Personal history of certain other diseases.
Legal Intervention: While Y35 Legal intervention has many codes to describe modern-day mechanisms of injury to a suspect, bystander, or law enforcement official resulting from a legal intervention, there are no codes for unspecified persons. Beginning Oct. 1, 2019, there are new codes to:
specify “unspecified person injured,”
differentiate between “manhandling” and “bodily force”
specify legal intervention involving injury by a conducted energy device such as a taser
Subsegmental Pulmonary Embolism (SSPE): Category I26 Pulmonary embolism has two new codes to improve specificity over existing code I26.99 Other pulmonary embolism without acute corpulmonale. The new codes are:
I26.93 (Single subsegmental pulmonary embolism without acute corpulmonale)
I26.94 (Multiple subsegmental pulmonary emboli without acute corpulmonale)
Travel Health Counseling: In accordance with a request from the American Academy of Pediatrics, a new code has been added to identify travel health-related encounters:
Z71.84 Encounter for health counseling related to travel
This code should be used for travel health counseling services provided to patients and caregivers unrelated to a preventive medical care encounter.
These are just a few of the code changes that will take effect on October 1, 2019. Partnering with an experienced medical billing outsourcing company providing coding and medical billing services can help practices ensure accurate ICD-10 coding to prevent claim denials and ensure adequate reimbursement for services rendered.
The American Medical Association (AMA) has published the office and outpatient evaluation and management (E/M) CPT code changes that they intend to make in 2021. Understanding how to properly document and code Evaluation and Management (E/M) patient visits is crucial for family practice physicians to optimize medical billing and maximize payment. Partnering with an experienced family practice medical billing company helps many providers achieve these goals and avoid the risk of payer audits.
Medicare announced documentation-related changes for office/outpatient E/M visits (CPT codes 99201 through 99215) in its proposed 2019 physician fee schedule (PFS). Announced by the AMA CPT Editorial Panel in its February 2019 meeting, the new CPT E/M modifications impact only Office or Other Outpatient Services (99201-99205 and 99211-99215) codes. Unless the AMA makes further modifications, the following office and outpatient E/M coding changes will take effect January 1, 2021:
Deletion of level outpatient visit CPT code 99201: Code 99201 Office or other outpatient visit for the evaluation and management of a new patient, will be deleted due to low utilization. Code 99201 requires 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making (MDM). The current guideline is to all 3 components to establish the level of a new office/outpatient encounter, and to use 2 out of the 3 elements to establish the level of an established office/outpatient Time can also be used if counseling and coordinating dominate the encounter.
History and exam will not have a role in office/outpatient E&M code selection: Starting Jan. 1, 2021, history and exam elements will no longer be factored into office/outpatient E&M code selection, though they will be necessary to report the office/outpatient E&M service. Instead, the codes will be selected either by total time or by level of medical decision-making.
Change in definition of “time”: The definition of time associated with 99202-99215 has been changed from “typical face-to-face time” to “total time spent on the day of the encounter.” Starting 2021, physicians will no longer need to establish how much time was devoted to counseling and coordinating on the day of the encounter. The time values associated with each office/outpatient E&M code will reflect the total time spent on the day of the encounter.
Revisions to the MDM elements associated with codes 99202-99215: There will be changes to the wording of the MDM elements:
Number of Diagnoses or Management Options” will change to “Number and Complexity of Problems Addressed”
“Amount and/or Complexity of Data to be Reviewed” will change to “Amount and/or Complexity of Data to be Reviewed and Analyzed”
“Risk of Complications and/or Morbidity or Mortality” will change to “Risk of Complications and/or Morbidity or Mortality of Patient Management
Additional E/M documentation changes: An AAPC report listed the AMA’s other E/M proposals as follows:
Guidelines for hospital observation, hospital inpatient, consultations, Emergency Department, nursing facility, domiciliary, rest home, custodial care, and home E&M services will not change. The AMA proposes restructuring E/M guidelines into three sections:
Guidelines Common to All E/M Services
Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care and Home E/M Services”
Guidelines for Office or Other Outpatient E/M Services, to distinguish the new reporting guidelines for the Office or Other Outpatient Services codes 99202-99215
Adding new guidelines that are applicable only to Office or Other Outpatient codes (99202-99215); adding a Summary of Guideline Differences table of the differences between the different sets of guidelines
Revising existing E/M guidelines to ensure there is no conflicting information between the different sets of guidelines
Adding a MDM table applicable to codes 99202-99215
Adding guidelines for reporting time when more than one individual performs distinct parts of an E/M service
Changes to Prolonged Services: Proposed updates include:
Revising codes 99354 and 99355 to exclude reporting of Office and other Outpatient Services codes
Revising code 99356 to include observation
Adding a new code to report prolonged office or other outpatient E/M services
These updates will have implications for documenting E/M services and assigning codes. Payers, including Medicare, have their own set of guidelines for claim submission. Physicians need to be knowledgeable about payer guidelines and policies to ensure accurate CPT coding and error-free claim submission. Family practicemedical coding and billing services are a good option to prepare for these E/M changes in 2021.