Industry News

E/M Coding Guideline Changes

Effective January 1, 2020, the appropriate level of E/M services will be based on: The level of the Medical Decision Making (MDM) as defined for each service; OR, The total time for E/M services performed on the date of the encounter. This change removes History and Exam from the E/M level calculation in hopes to simplify documentation requirements and reduce some of the administrative burden. Additionally, CPT 99201 has been deleted.

Modifications to the criteria for MDM:
• Create sufficient detail in CPT code set to reduce variation between contractors/payers
• Attempt to align criteria with clinically intuitive concepts
• Use existing CMS and contractor tools to reduce disruption in coding patterns
• Remove ambiguous terms (eg, “mild”) and defined previously ambiguous concepts (eg, “acute or chronic illness with systemic symptoms”)

The Level of Medical Decision Making Table will guide to assist in selecting the level of MDM and is to be used only for office or other outpatient E/M services. Unchanged from current levels of MDM the 2021 levels include: Straightforward; Low; Moderate; and, High.

The proposed rule also revalues and increases payment rates for CPT codes related to these E/M services, typically delivered by primary care providers. Therefore, those physicians with a greater share of  E/M services will see a pay bump. For example, the rule estimates an increase in the impact of total allowed charges to family practice (+13%), general practice (+8%), endocrinologists (+17%) and rheumatologists (+14%). However, to offset the increased value to E/M services, the rule also comes with an unusually large budget neutrality adjustment. CMS is proposing to reduce the PFS conversion factor by 10.61% for CY 2021. Therefore, many specialties with a lower use of E/M services, such as those billing for procedures, will receive a large decrease in Medicare reimbursement these include radiologists (-11%), vascular surgeons (-7%), pathologists (-9%) and nurse anesthetists (-11%).

The AMA provides numerous resources on the E/M guidelines and coding changes. Or, reach out to your revenue cycle management partner for more information and training on the implementation of these new guidelines.