Changes to payment, coding, and documentation policies for evaluation and management (E/M) services finalized in the 2019 Physician Fee Schedule (PFS) final rule are necessary to align with the American Medical Association’s (AMA) revisions to the 2021 CPT code set for office/outpatient E/M visits, according to the Centers for Medicare & Medicaid Services (CMS).

The proposed policy changes for E/M visits are outlined in the 2020 PFS proposed rule.

Proposed Policies for E/M Services

CMS is proposing to largely adopt “their interpretation” of AMA’s alternative approach to CPT E/M office or other outpatient visit reporting guidelines and code descriptors, effective for Jan. 1, 2021. This includes deleting CPT code 99201 (Level 1 office/outpatient visit, new patient) and assigning separate payment rates to each of the remaining E/M codes.

Proposed E/M policy changes for 2021 include:

• Basing code selection on time or medical decision making (MDM) rather than history and exam.
• New interpretive guidelines by CPT for levels of MDM.
• New times in the code descriptors that include all practitioner time the day of the visit.
• New CPT code for prolonged services in lieu of GPR01 and CPT codes 99358 (Prolonged service w/o contact, first hour) and +99359 (each additional 30 minutes).
• Accepting the AMA RUC-recommended value increases for all E/M codes, effective Jan. 1, 2021 (see Tables 1 and 2).

Table 1: New patient rates

Table 2: Established patient rates

• A new prolonged services code for additional time spent with patients beyond the level 5 visit, with an approximate payment rate of $35.
• Consolidating the two add-on HCPCS Level II G codes finalized last year for primary care and certain non-procedural specialty care into a single code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious or complex chronic condition, with a proposed payment rate of approximately $17.

Tell CMS What You Think

CMS is seeking input on policies related to CPT codes 99358 and 99359. Specifically, whether it would be appropriate to interpret AMA’s CPT reporting instructions as proposed.

In question is whether to include CPT code 99211 in the list of base codes that cannot be reported with 99358 and 99359. “We do not believe CPT code 99211 should be included in the list of base codes since it will only include clinical staff time,” CMS states in the 2020 PFS proposed rule. See page 504 in the 2020 PFS proposed rule for details.

CMS is also seeking comment on its proposal to revise the descriptor for HCPCS Level II code GPCIX (see Table 28 in the 2020 PFS proposed rule) and delete HCPCS Level II code GCGOX, among other proposals. See Section II.P Payment for Evaluation and Management (E/M) Visits in the 2020 PFS proposed rule for complete details pertaining to E/M policy.

Commenting instructions are found at the beginning of the 2020 PFS proposed rule.  All comments are due by 5 p.m. ET on Sept. 27, 2019.

Prepare for Change

The AMA has made available for download two documents that may help you prepare for commenting and the policy changes ahead.

AMA Essential Tools & Resources:

CPT E/M Office or Other Outpatient and Prolonged Services Code and Guideline Changes

CPT E/M Office Revisions Level of Medical Decision Making (MDM)

Resource:

MLN listening session, “Physician Fee Schedule Proposed Rule: Understanding 3 Key Topics,” Aug. 12, 2019