As part of the Centers for Medicare and Medicaid Services (CMS) “Patients Over Paperwork” initiative, changes in coding, payment, and documentation requirements for E/M Office or Outpatient Services (99201-99205 and 99211-99215) are being implemented as an effort to reduce administrative burden, increase payment accuracy, and decrease unnecessary documentation in the medical record. 

In December 2019, WCA conducted a physician webinar explaining the changes and how they relate to wound care. A summary of the webinar is below.  For a more detailed review of these changes, click HERE to view WCA’s “2021 Physician E/M Updates“ on-demand webinar.

Effective January 1, 2021, new reporting guidelines will be implemented and code selection for office/outpatient E/M services will be based on:

1. Eliminate history and physical as elements for code selection:

The history and physical examination elements will no longer be factored into the office/outpatient E/M code selection.    

2. Providers are allowed to select codes based on Medical Decision Making (MDM) OR Total Time:

Medical Decision Making
The three elements of MDM (number and complexity of the patient’s presenting problem, data to be reviewed and risk) were revised and numerous clarifying definitions were created in the E/M guidelines. 

Time

The definition of time will change from “typical face-to-face time” to “total time spent on the day of the encounter.” Providers will now focus on increments of time for face-to-face and non-face-to-face time personally spent by the physician or other qualified healthcare professional on the date of the encounter (i.e. preparation for the visit, performance of a medically appropriate examination and orders for medications, tests or other procedures.)
 

3. Modifications to the criteria for MDM:

The revised required elements for MDM include: 

• Removed ambiguous terms (e.g. “mild”) and defined previously ambiguous concepts (e.g. “acute or chronic illness with systemic symptoms”)

• Also defined important terms, such as “Independent historian”

• Re-defined the data element to move away from simply adding up tasks to focusing on tasks that affect the management of the patient (e.g. independent interpretation of a test performed by another provider and/or discussion of test interpretation with an external provider)

4. Deletion of E/M code 99201:

E/M code 99201, office or other outpatient visit for the evaluation and management of a new patient, will be deleted due to low utilization.

5. Creation of New Single Prolonged Services Code:

A shorter prolonged services code, CPT Code 99417, will be used to capture provider time in 15-minute increments instead of codes 99354 and 99355. This code would only be reported with 99205 and 99215 and be used when time was the primary basis for code selection. 

6. Documentation Rules Staying the Same:
The authentication rules have not changed and the chief complaint will continue to be required for each E/M visit. The history and exam have been eliminated for code selection and only need to be performed and documented for the visit when medically necessary and clinically appropriate. In spite of these new changes, physician documentation must still accurately depict what has led up to and occurred during the encounter in order to meet medical necessity for procedures and services performed.