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2021 Office/Outpatient E/M Services Updates for Wound Care and HBOT

2021 Office/Outpatient E/M Services Updates for Wound Care and HBOT

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2021 Office/Outpatient E/M Services Updates for Wound Care and HBOT

INTRODUCTION

Overview

As of January 1, 2021, evaluation and management (E/M) CPT® codes 99202-99215 can be selected on the basis of the complexity of the medical decision making (MDM) or on the basis of the total time on the date of the encounter. This topic provides a summary of the main updates, along with a printable point-of-care tool that includes sample verbiage for support documentation of MDM in wound care and hyperbaric and oxygen therapy (HBOT). See 'Quick Reference Tool for Coding of Office/Outpatient E/M Services' below.

Background

Summary of changes to E/M codes in 2021

  • The summary below is based on the American Medical Association's "CPT Evaluation and Management (E/M) Office or Other Outpatient (99202 - 99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes".[1]
  • CPT® code 99201 (new patient, level 1) was deleted. Code 99211 (established patient, level 1) remains as a reportable service, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter.
  • Criteria for code selection is based on either:
    • 1) The level of medical decision making (MDM) OR
    • 2) The time performing the service on the day of the encounter. Counseling and/or coordination of care do NOT need to be more than 50% of the time spent when coding based on time.
  • History and examination are no longer key for code selection.
  • Definition of time for codes 99202-99215 has been revised from the typical face-to-face time to total time spent on the day of the encounter.
  • There are 3 medical decision-making elements.
    • 1) The number and complexity of problems addressed
    • 2) Amount and/or complexity of data to be reviewed and analyzed AND
    • 3) Risk of complications and or morbidity or mortality of patient management
  • The level of MDM is selected based on 2 out of 3 elements of MDM. For instance, if in a given case the "Number and Complexity of Problems" is Low, "Amount and/or Complexity of Data to be Reviewed and Analyzed" is Moderate, and "Risk of Complications and/or Morbidity/Mortality of Patient Management" is Moderate, MDM is moderate and CPT® is 99204 or 99214.[1]
  • New Prolonged Services CPT® code 99417: for use when outpatient E/M services exceed each 15 minutes beyond the highest level E/M code (99205, 99215). It can only be reported when the E/M service has been selected based on time alone (not MDM).  


Billing for E/M services and procedures on the same day

  • The physician or other qualified health care professional may need to indicate that on the day a procedure or service identified by a CPT® code was performed, the patient’s condition required a significant separately identifiable E/M service. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.[1]
  • It is important to preface by noting that payment for diagnostic (with the exception of pathology and laboratory) and/or therapeutic procedure(s) (code ranges 10040-69990, 70010-79999 and 90281-99140) already includes taking the patient’s blood pressure, temperature, asking the patient how he/she feels and getting the consent form signed. Since payment for these types of services is already included in the payment for the procedure, it is not appropriate to bill for an Evaluation and Management (E/M) service separately. 
  • See section 'Billing for evaluation and management and procedures on the same day' in topic "Coding and Billing Essentials in Wound Care"

QUICK REFERENCE TOOL

See the 'Quick Reference Tool for Coding of Office/Outpatient E/M Services' below (Algorithm 1)

Algorithm 1. Quick Reference Tool for Coding of Office/Outpatient E/M Services (click on this link to enlarge)[1]


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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202 - 99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes . 2021;.
Topic 1594 Version 1.0