Evaluation & Management for Office, Outpatient, and Home Visits

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This author/consultant recently had the honor of providing a coding, payment, and coverage symposium to a large group of wound/ulcer management physicians and other qualified healthcare professionals (QHPs) from all over the country. One of the topics that we discussed was the historic revision of the evaluation and management (E/M) codes that began in 2021 and that will be completed on January 1, 2023. Surprisingly, most of the physicians and QHPs in the audience had no idea that guidelines for office and outpatient E/M services changed on January 1, 2021, and that the guidelines for most of the other E/M service codes will change on January 1, 2023.

Because wound/ulcer management physicians and QHPs perform most of their E/M service work in their offices, hospital owned outpatient wound/ulcer management provider-based departments (PBDs), and in patients’ homes (particularly since the COVID-19 public health emergency was declared), they asked many questions about reporting E/M services in those places of service. Therefore, this article shares some of the major questions and answers about reporting E/M services performed in offices, PBDs, and patients’ homes.

Q: Because no one educated me about the 2021 E/M service changes, will you please provide a high level overview of the changes?

A: The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) worked hard to decrease administrative burden, decrease the need for audits, decrease unnecessary documentation in the medical record that is not needed for patient care, and to ensure that payment for E/M service is resource-based and does not redistribute payment between specialties. Because changing the E/M service guidelines for all places of service, all at once, would have been a daunting implementation task for physicians and QHPs, even though it simplified their documentation and coding, the American Medical Association (AMA) and CMS agreed to first implement the E/M service changes for work performed in offices and PBDs. The major changes are:

• The history and examination are no longer used to select the level of office/outpatient E/M service codes, but medically appropriate history and/or physical examination should still be performed at the visit. The nature and extent of the history and/or physical examination should be determined by the physician or QHP.
• E/M level 1 office/outpatient visit code (99201) for a new patient was deleted
• E/M levels 2–5 new and established office/outpatient codes are now based on:
  · Level of medical decision making (MDM) (as redefined in the new AMA/CPT^® Codebook¹), or
  · Total time personally spent by the reporting physician/QHP on the day of the encounter (including face-to-face and non-face-to-face time). NOTE: Time does not apply to 99211

Q: What type of activities are included in the total time?

A: The major activities that wound/ulcer management physicians and QHPs may count when reporting E/M by time are:

• Preparing to see patient (review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing medically appropriate examination and/or evaluation
• Counseling and educating patient, family, and/or caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals (when not separately reported)
• Documenting clinical information in electronic or other health record
• Independently interpreting and communicating results (not separately reported) to patient, family, and/or caregiver
• Care coordination (not separately reported)

Q: What amount of time is attached to each office/outpatient E/M service code?

A: First, remember that 99201 was deleted and that 99211 is not reported based on time.

Second, following are the times currently attached to the office/outpatient E/M service codes:

New Patient
99202             15–29 minutes
99203             30–44 minutes
99204             45–59 minutes
99205             60–74 minutes
 
Established Patient
99212             10–19 minutes
99213             20–29 minutes
99214             30–39 minutes
99215             40–54 minutes
 
Third, when the physician or QHP decides to report a particular E/M encounter based on time, she/he should document the specific activities performed and the total time of the encounter. NOTE: Physicians and QHPs should inquire if their Medicare Administrative Contractor and other contracted payers have specific guidelines regarding documenting E/M time.   

Q: Did the AMA provide new medical decision making (MDM) elements and guidelines for selecting the office and outpatient E/M codes?

A: Yes, the CPT^® Codebook clearly reviews the new MDM elements and guidelines which align with the E/M service code descriptions. All physicians and QHPs should take the time to carefully read the E/M section of the CPT^® Codebook and make a concerted effort to align their documentation and coding with the new guidelines. In addition, the AMA website has many free job aids and tools to assist physicians, QHPs, coders, billers, and the entire revenue cycle team in understanding the new office and outpatient E/M elements and guidelines.

Q: I am a physician who provides wound/ulcer management services in my office, in the PBD, and in patients’ homes. Effective January 1, 2021, my coders insisted that I report my E/M services performed in the office and PBD based on the new MDM guidelines or total time but insisted that I use the 1995 or 1997 E/M guidelines to report E/M services performed in the patients’ homes. Was I correct to report based on two significantly different sets of E/M guidelines?

A: Yes, in 2021 and 2022 physicians and QHPs were required to follow two sets of E/M service guidelines if they worked in places of service other than the office and the PBD. You should thank your coder for steering you in the right direction. In addition, both you and your coder should be happy that you will only have one set of E/M service guidelines beginning on January 1, 2023.

Q: For every patient encounter, should I document both total time and according to MDM?

A: For each patient encounter, the physician or QHP should choose whether total time or MDM best represents the work performed and should document accordingly. However, the E/M service level methodology does not need to be the same for all of that patient’s encounters. In other words, a patient encounter today could be documented and reported based on total time and the next encounter (for the same patient) could be documented and reported based on MDM.

Q: Is it possible for a physician or QHP to perform a procedure such as a debridement, to manage a significant separately identifiable problem, and to report the E/M service based on time?

A: Yes, it is possible, but the physician or QHP must carefully document the two distinct services. In addition, the time spent performing the procedure should not be included in the total time that will be used to determine the E/M service code.

Q: Did the Medicare allowable payment rates for the office and outpatient E/M services change when the guidelines changed?

A: That is a great question. Table 1 displays the Medicare national average allowable rates in 2020 (when the 1995 and 1997 E/M service guidelines were in place), in 2021 (when the new MDM and total time guidelines were implemented), and in 2022 (the second year for the MDM and total time guidelines).

Q: Is it true that, effective January 1, 2023, the AMA and CMS will stop using the 1995 and 1997 E/M guidelines, for other places of service?

A: Yes. As promised, the AMA and CMS created some new E/M service odes, revised some E/M service codes, and consolidated some E/M service codes used to report the following:

• Hospital inpatient and observation care services
• Consultations
• Emergency Department services
• Nursing facility services
• Home or residence services
• Prolonged services

In addition, the AMA and CMS provided guidelines, similar to those for the office and outpatient E/M services. The 2023 CPT^® Codebook describes the total time requirements and the MDM elements required to report the E/M services listed above. Physicians, QHPs, coders, and billers should not use the 1995 or 1997 guidelines to determine E/M service codes for dates of service on or after January 1, 2023. NOTE: Revenue cycle team members should not forget the 1995 and 1997 guidelines, because they will still be needed to appeal denials and to defend against negative audits of claims submitted for encounters performed prior to January 1, 2023.

Q: Many wound/ulcer management physicians and QHPs are now performing E/M services in patients’ homes. Will you share the changes that were made to those E/M service codes?

A: That is a great question because significant changes have been made to this section of the 2023 CPT^® Codebook. In fact, even the title of the subsection in the book is changed from “Home Services” to “Home or Residence Services.” Some of the other changes are:

• One of the new patient home visit E/M service codes, 99343, was deleted because its MDM requirement (moderate level) is identical to 99344.
• The definition of “home” has not changed. It is still defined as a private residence, temporary lodging, or short-term accommodation such as a hotel, campground, hostel, or cruise ship.
• For coding purposes, the AMA clarified the locations that are considered residences: assisted living facility, group home that is not licensed as an intermediate care facility for patients with intellectual disabilities, custodial care facility, or residential substance abuse treatment facility.
• “New patient” home or residence E/M services should be reported with 99341, 99342, 99344, and 99345, whose definitions have been revised to align with the new E/M service level guidelines.
• The requirements for E/M service code selections have been revised and now require either the appropriate level of MDM that is defined for each service, or the total physician or QHP time on the date of the encounter. Although not required to select an E/M service level, a medically appropriate history and/or examination should be determined, performed, and documented by the physician or QHP.
• The domiciliary and rest home codes (99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337) and home care plan oversight services codes (99339, 99340) have been deleted. Those E/M services provided to “new patients” may be reported with 99341, 99342, 99344, and 99345, and the E/M services provided to “established patients” may be reported with 99347-99350.

Q: What amount of time is affiliated with each home or residence service E/M code?

A: The revised descriptions of the home or residence service E/M service codes specify the time affiliated with each code:

            New Patient
            99341 15 minutes must be met or exceeded
            99342 30 minutes must be met or exceeded
            99344             60 minutes must be met or exceeded
            99345             75 minutes must be met or exceeded
 
            Established Patient          
            99347             20 minutes must be met or exceeded
            99348 30 minutes must be met or exceeded
            99349             40 minutes must be met or exceeded
            99350 60 minutes must be met or exceeded
NOTE: Travel time should not be counted when determining the E/M service level.

Author’s Thoughts

The new E/M service level guidelines should be welcomed and embraced by wound/ulcer management physicians and QHPs. Rather than spending time to document superfluous information that was required by the 1995 and 1997 E/M guidelines, these specialists can now determine exactly what type of history and examination is required for each patient encounter. Then they can decide if the encounter is best reported based on their level of medical decision making or total time spent face-to-face and non-face-to face on the day of the encounter. In addition, physicians and QHPs should have more time to document the services that they did provide to the patient.

Documentation is still very important, but now it can be focused on the encounter. If the physicians or QHPs decide to report an encounter based on total time, they should remember a few important guidelines:

• Do not count clinical staff time in the total time the physician or QHP spent during the encounter.
• Do not double-dip by including the time spent in a procedure when determining the level of a significant separately identifiable E/M service performed during the same encounter.

Finally, following are a few “to-dos” that physicians and QHPs should do now to prepare for the 2023 implementation of the new E/M service level guidelines:

• Read the 2023 CPT Codebook E/M services guidelines carefully and learn the definitions of the new guidelines
• Download and read the plethora of E/M service materials that AMA has published on their website
• Stop using history and examination to determine E/M service codes, but do not abandon obtaining medically necessary history and performing a medically necessary examination at each encounter
• Update documentation templates to only include what is medically indicated for each patient’s presenting problem and the complexity of the encounter, and to collect time if the physician or QHP intends to report based on total time related to a patient’s visit on the day of the encounter
• Turn off the copy-and-paste feature of your electronic health record
• Practice coding with the new MDM grid that is described in detail in the 2023 CPT Codebook and in the materials that are on the AMA’s website
• To determine if your business is equipped to accurately track total, practice recording and reporting by total time.  
• Contact private payers with whom the physician or QHP is contracted to verify if and how they will cover for E/M services based on time

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@gmail.com.

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Reference

1. 2023 CPT Codebook. The American Medical Association. 2022.