E/M codes: AMA keeps pace with CMS

May 24th, 2019 / By Rebecca Caux-Harry

In March, the American Medical Association (AMA) published their CPT Editorial Summary of Panel Action February 2019.  The summary warns that final CPT codes and descriptors are still in draft format and won’t be finalized until just prior to publication. The summary is indeed brief, but there’s a lot to absorb with regard to office E/M coding.

As most of you are aware, CMS has decided to update the Evaluation and Management guidelines to keep pace with current technology and practice of medicine in the clinical setting. In so doing, CMS has decided to flatten the payment for levels 2, 3, and 4 for new and established patients in a clinical setting; CPT codes 99211-99215 and 99201-99215. As a result of this update, the AMA has responded in alignment with CMS and plans to have the changes effective January 1, 2021, the same date the new documentation and coding guidelines go into effect from CMS.

CPT code 99201 will be deleted with the remaining nine codes getting revised direction. Current guidelines state that there are three key components: history, exam and medical decision making (MDM). In 2021, history and exam will be demoted and no longer considered key components. The summary states that “a medically appropriate history and/or examination must be performed in order to report codes 99202-99215.” As a coder/auditor, I’m not qualified to determine what level of history or exam is medically necessary for any patient, and luckily, I won’t have to. The sole remaining key component is medical decision making, which aligns perfectly with CMS’ direction. So, physicians can code their services based entirely on MDM provided they document the history and exam elements they deem medically relevant. Alternately, they can still code based on time and the AMA has revised this direction as well. Currently, our code descriptors include typical time spent providing face-to-face care. In 2021 the direction will change to total time spent on the day of the encounter, and time values will be revised as well. This revision is welcome and recognizes that physicians provide a great variety of care, even when not face-to-face with their patients. The AMA is assigning value to that important time.

As for the MDM section of the guidelines, the subsections’ titles are rewritten with greater clarity. For example, “Number of Diagnosis or Management Options” will change to “Number and Complexity of Problems Addressed.” To me, the renaming of this subsection brings to mind MEAT criteria (Monitor, Evaluate, Assess, Treat). In other words, we shouldn’t be counting/coding a condition unless it was addressed. We will see revisions to the general E/M guidelines as well as get a table of differences. All good stuff in my mind, but I’m also thinking about the result of these updates. And remember, these revisions only apply to Office/Outpatient new or established patients. I think we can assume that these revisions, or something similar, will be made to the remaining E/M codes once we’ve adjusted.

So, the results, or I should say potential results. For established patients, we will essentially have three options for office visits: 99211, 99212-4, 99215. CPT code 99211 doesn’t require the presence of a physician. That one is easy. For the remaining two options, the only difference aside from reimbursement is the MDM or time. Think about it; A single element will determine the level of care. And, if the physician codes 99212, 99213 or 99214, it doesn’t matter as there is no compliance risk. The reimbursement is the same for Medicare. I haven’t seen anything from commercial payers about payment for these codes yet.  And for new patients, the documentation guidelines will be exactly the same! Nice.

So, the value of history and exam templates will go away, note bloat will go away, compliance risk will be reduced and hopefully this update will free up physician time and decrease their administrative burden. But, with this update, I think we can clearly see our future in professional coding. The “what” becomes less important and the “why” becomes much more important. CMS and the AMA are giving us fair warning. ICD-10-CM coding is our future. 

Rebecca Caux-Harry, CPC, is a professional fee coding specialist with 3M Health Information Systems.