The New Year’s Impact on CPT Codes

December 8, 2020 | Article

By Susan Rohde and Rachel Pugliano

The new year will usher in a major change to CPT codes, most notably for Evaluation and Management (E/M) coding guidelines.

What changes are impacting CPT Codes?
Starting January 1, 2021, there will be over 329 changes, including 206 new codes, 54 deletions and 69 revisions.

CPT Codes within the E/M Section
The first major overhaul to the E/M guidelines in over 25 years came in the form of revamping the office/outpatient visit code set.  In an initiative the Center for Medicare and Medicaid Services (CMS) is calling “Patients Over Paperwork”, codes 99202-99215 will now be selected utilizing Medical Decision Making (MDM) or Total Time, thus eliminating the History and Exam components.  While these coding guidelines are created by the AMA, the organization that maintains CPT codes through the CPT Editorial Panel, CMS did adopt these revised coding guidelines as part of its Medicare Physician Fee Schedule in 2021.  This will promote consistency within the E/M code set.

Providers and staff will still need to understand the 1995 and 1997 E/M guidelines, as they continue to pertain to coding Inpatient, Observation, Nursing Facility and Emergency Department visits.  The 1995/1997 guidelines include three key components, History, Exam and Medical Decision Making (MDM).  January 1, 2021 documentation guidelines will be streamlined, potentially deleting excessive documentation or “note bloat” and providing more time to be spent on direct patient care.

While MDM did not change drastically from the 1995/1997 guidelines, a new MDM table was created with easier to understand verbiage and definitions. 

Providers will now get credit for the following:

  • Reviewing prior external notes from each unique source.
  • Reviewing the results of each unique test, including imaging, lab, psychometric or physiologic data.
  • Ordering each unique test.
  • Performing an assessment requiring an independent historian, defined by the AMA as an individual who supplements information provided by a patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia or psychosis) or because a confirmatory history is deemed necessary. Examples include a parent, guardian, surrogate, spouse or witness.
  • Independently interpreting a test performed by another physician or other qualified health care professional (QHP). Note that physicians and QHPs can only count this toward the MDM when they cannot report the service using another CPT code.
  • Discussing patient management or test interpretation with an external physician or other QHP (i.e., someone who is not in the same group or who is in a different specialty or subspecialty, a licensed professional practicing independently, a hospital, nursing facility or home health care agency), or another appropriate source (e.g., lawyer, parole officer, case manager or teacher). It does not include discussion with family or informal caregivers. Note that physicians and QHPs can only count this toward the MDM when they cannot report the service using another CPT code.

CPT code 99201 will be deleted in 2021, as the MDM for 99201 is identical to 99202, and there was no need for duplicate codes.

Time Component in E/M Section
The time component will see the greatest change.  For 2021, total time will be the basis of code selection, rather than 50% counseling and/or coordination of care.  Providers may now count total time of the visit on the date of the encounter, including face to face and non-face to face time.  Eligible factors for time include:

  • Care coordination (when not separately reportable).
  • Counseling and educating the patient, family and/or caregiver.
  • Documenting clinical information in the electronic or other health record.
  • Independently interpreting results (when not separately reportable) and communicating results to the patient, family and/or caregiver.
  • Getting and/or reviewing separately obtained history.
  • Ordering medications, tests or procedures.
  • Performing a medically appropriate exam and/or evaluation.
  • Preparing to see the patient (e.g., reviewing tests).
  • Referring the patient to and communicating with other health care professionals (when not separately reportable).

Medicare Final Rule
In the Medicare Final Rule, CMS did not agree with the AMA/CPT final descriptor of prolonged care code 99417, which allows providers to assign when total time exceeds the minimum time for 99205 and 99215.  For Medicare patients, assign code G2212, which requires the total visit time to exceed the maximum time for 99205 and 99215. We recommend checking with private payors to see if they prefer 99417 or G2212.

The Final Physician Fee Schedule also included the addition of HCPCS code G2211, (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed healthcare services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. [Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established]).  This code replaces the “placeholder” code GPCIX that was in the Proposed Rule.  CMS states around 90% of E/M encounters will be eligible for this add-on code and will provide an approximate $16 of additional payment per claim, with an RVU of .33.  The code was finalized to help offset the decreased conversion factor that was necessary to maintain budget neutrality.

This code may be added on to any level office visit (99202-99215), by any specialty, when treating practitioner provides appropriate documentation to support increased complexity.  CMS provides two indicators for proper assignment of code G2211:

  1. The physician or qualified health care professional (QHP) provides one or more care management services to the patient. You’ll find a complete list in Table 17 of the Final Rule, but services include advance care planning, prolonged services with an office visit, treatment and management based on remote physiologic monitoring data and any of the non-face-to-face care management services such as chronic care management.
  2. The physician or QHP routinely provides preventive services for the patient.

CMS also provides scenarios in the Final Rule which this code may be utilized. Please refer to your 2021 CPT Manual for more inclusive information and additional examples regarding the use and misuse of code G2211.  While code G2211 may be appropriate in several scenarios, it would not be appropriate to assign when a provider simply treats a patient from time to time for an acute condition as CMS would describe this as “discrete, routine or time-limited”.  Instances such as removal of a mole, treatment of a fracture, and counseling for allergies do not justify the assignment of HCPCS code G2211.

CMS does expect a high volume of utilization for code G2211; and will be monitoring for appropriate use. They  will issue additional guidance in the coming months. As of the date of this article, code G2211 will only be reimbursed by Medicare.

As a reminder CPT uses the following symbols
● New CPT code
▲ Revised CPT code
# Resequenced CPT code
+ Designated add-on CPT code

# ✚ ● 99417  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 Evaluation and Management services)

(Use 99417 in conjunction with 99205, 99215)
(Do not report 99417 in conjunction with 99354, 99355, 99358, 99359, 99415, 99416)
(Do not report 99417 for any time unit less than 15 minutes)

G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
(Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416).
(Do not report G2212 for any time unit less than 15 minutes)).

Time Thresholds Per AMA/CPT

Total Duration of new Patient or Other Office or Other Outpatient Services (use with 99205) Code(s)
less than 75 minutes Not reported separately
75-89 minutes 99205 X 1 and 99417 x 1
90-104 minutes 99205 X 1 and 99417 x 2
105 or more 99205 X 1 and 99417 x 3 or more for each additional 15 minutes.
Total Duration of new Patient or Other Office or Other Outpatient Services (use with 99205) Code(s)
less than 55 minutes Not reported separately
55-69 minutes 99215 X 1 and 99417 x 1
70-84 minutes 99215 X 1 and 99417 x 2
85 or more 99215 X 1 and 99417 x 3 or more for each additional 15 minutes.

Time Thresholds Per CMS

CPT Code(s) Total Time Required for Reporting
99205 60-74 minutes
99205 x 1 and G2122 x 1 89-103 minutes
99205 x 1 and G2122 x 2 104-118 minutes
99205 x 1 and G2122 x 3 or more for each additional 15 minutes. 119 or more

Documentation will be key in assigning clinic/outpatient visit E/M codes in 2021.  Medical necessity, the overarching criterion when choosing an E/M code, is still applicable in 2021.  For example, it would not be prudent to assign a code based on time if 50 minutes was spent for an ear infection.  The practice or facility will also want to contact other payors, as these changes are specific to Medicare. Although these codes are released by the AMA in the CPT manual., some payors may continue to require E/M code selection based on history, exam and MDM.

2021 CPT Code Changes
For the rest of the  CPT changes, the AMA stated “The CPT code set continues to see growth in the new and novel areas of medicine, with the majority (63%) of new codes this year involving new technology services described in Category III CPT codes and the continued expansion of the Proprietary Laboratory Analyses (PLA) section of the CPT code set”. 

COVID-19 public health emergency codes
Among these changes, new codes were implemented earlier in the year, due to the COVID-19 public health emergency (PHE) including:

87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique. Effective March 13, 2020.

86328 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) to report single step antibody testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Effective April 10, 2020.

86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) to report multiple-step antibody testing for SARS-CoV-2. Effective April 10, 2020.

0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected to report the BioFire® Respiratory Panel 2.1 (RP2.1) proprietary laboratory analyses (PLA) tests. Effective May 20, 2020.

99072 – Additional supplies, materials and clinical staff time over and above those usually included in an office visit or other nonfacility service(s), when performed during the Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

Early Release Codes
Other early release codes effective October 1, 2020 include:

0015M Adrenal cortical tumor, biochemical assay of 25 steroid markers, utilizing 24-hour urine specimen and clinical parameters, prognostic algorithm reported as a clinical risk and integrated clinical steroid risk for adrenal cortical carcinoma, adenoma, or other adrenal malignancy

0016M Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)

Cardiovascular
The Cardiovascular Surgery section saw changes within the shunting section with three new codes added and two deletions (92992/92993).  The additions are as follows:

►Codes 33741, 33745 are used to report creation of effective intracardiac blood flow in the setting of congenital heart defects. Code 33741 (transcatheter atrial septostomy) involves the percutaneous creation of improved atrial blood flow (eg, balloon/blade method), typically in infants ≤4 kg with congenital heart disease. Code 33745 is typically used for intracardiac shunt creation by stent placement to establish improved intracardiac blood flow (eg, atrial septum, Fontan fenestration, right ventricular outflow tract, Mustard/Senning/Warden baffles). Code 33746 is used to describe each additional intracardiac shunt creation by stent placement at a separate location during the same session as the primary intervention (33745). ◄

λλ33741 Transcatheter atrial septostomy (TAS) for congenital cardiac anomalies to create effective atrial flow, including all imaging guidance by the proceduralist, when performed, any method (eg, Rashkind, Sang-Park, balloon, cutting balloon, blade)

λλ33745 Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac flow, all imaging guidance by the proceduralist when performed, left and right heart diagnostic cardiac catherization for congenital cardiac anomalies, and target zone angioplasty, when performed (eg, atrial septum, Fontan fenestration, right ventricular outflow tract, Mustard/Senning/Warden baffles); initial intracardiac shunt

+ λλ33746 each additional intracardiac shunt location (Use 33746 in conjunction with 33745)

Audiology
Audiology was the other section that saw the most changes with three new codes added under auditory evoked potentials and deletions of codes 92585/92586.

Code 92650 is now a screening service.

Code 92651 was added to report post-screening follow-up for auditory evoked potential for hearing determination. Code 92652 was added for threshold estimation at multiple frequencies.

92650 Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis

#λ92651 for hearing status determination, broadband stimuli, with interpretation and report
#λ92652 for threshold estimation at multiple frequencies, with interpretation and report

Bronchospasm Test
A new code was added for exercise test for bronchospasm without the requirement of an electrocardiographic recording.

94617 Exercise test for bronchospasm, including pre- and post-spirometry and pulse oximetry; with electrocardiographic recording(s)

λλ94619 without electrocardiographic recording(s)

Other CPT Code Updates
The sections noted above are not all inclusive but do highlight the areas with the most changes.  Other areas with less extensive changes include:

  • Cardiology
  • Obstetrics and Gynecology
  • Ophthalmology
  • Otolaryngology
  • Orthopedic Surgery
  • Pathology
  • Plastic Surgery
  • Radiology
  • Interventional Radiology
  • Urology

The Impact of CPT Code Changes on Your Healthcare Organization
The 2021 CPT code changes, while not large in number, are comprehensive.  For an entire listing of all additions, deletions and revisions, visit the 2021 CPT Code Book.      The AMA also publishes a 2021 CPT Code Changes book that specifically lists the detailed changes. 

We encourage practices and facilities to review these changes with providers, affected clinical departments, update fee schedules and chargemasters and include revenue cycle, coders and billers in the conversations.


Unsure how to get started or have a question related to the changes?

Eide Bailly is available to assist in education and training for providers, clinicians and revenue cycle personnel as needs arise.

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