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Coding changes coming soon


There may be some positive changes coming to evaluation and management (E/M) services effective January 1, 2021. In the proposed calendar year 2020 Physician Fee Schedule (CY 2020 PFS), the Centers for Medicare & Medicaid Services (CMS) suggested a number of coding, payment, and documentation changes for office/outpatient E/M visits, Current Procedural Terminology (CPT®) codes 99201-99215. A summary of these changes include:

Dr. Michael Nelson

• Separate payment for the five levels of office/outpatient E/M visit CPT codes, as revised by the CPT Editorial Panel effective January 1, 2021. This would include deletion of CPT code 99201 (Level 1 new patient office/outpatient E/M visit) and adoption of the revised CPT code descriptors for CPT codes 99202-99215;

• Elimination of the use of history and/or physical exam to select among code levels;

• Choice of time or medical decision making to decide the level of office/outpatient E/M visit (using the revised CPT interpretive guidelines for medical decision making);

• Payment for prolonged office/outpatient E/M visits using the revised CPT code for such services, including separate payment for new CPT code 99XXX and deletion of Healthcare Common Procedure Coding System (HCPCS) code GPRO1 (extended office/outpatient E/M visit) that was previously finalized for 2021;

• Revise the descriptor for HCPCS code GPC1X and delete HCPCS code GCG0X; and

• Increase in value for HCPCS code GPC1X and allowing it to be reported with all office/outpatient E/M visit levels.

These changes were recommended by CMS to improve payment accuracy, reduce the administrative burden, and better reflect the current practice of medicine. These changes are predicted to result in a simplification of physician documentation and a redistribution of payments favoring providers who deliver primary care or care to more complex patients.

In CY 2019 PFS, CMS proposed to pay a single (blended) rate for office/outpatient visits 2-4, but due to comments from stakeholders, including specialty societies, CMS proposed to accept alternate recommendations by AMA/CPT. These recommendations include using medical decision making or time to determine the level of a visit, rather than the schema that was based on history and physical exam and outlined in the 1995/1997 guidelines. This resulted in elimination of CPT code 99201 and changes to the descriptors of 99202-99215. These codes were resurveyed by the Relative Value Update Committee (RUC) resulting in new values and times. (See Table 1).

One can see that there has been an incremental increase in time and value for most codes. When selecting a code based upon time, there is a range that is defined for each code,and additional information about the codes, including the descriptors and ranges, can be found on the AMA website

For CPT codes 99205 and 99215 (level 5 codes), an add-on code has also been proposed that would account for additional time spent above the new levels defined in the codes. The descriptor for CPT 99XXX (the final numbers have not yet been assigned) reads Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services). 99XXX is similar to CPT add-on code 99292 in that it may be used multiple times for a single encounter. This is illustrated in Table 2.

However, 99XXX is only used with level 5 codes. It will replace HCPCS code GPRO1, which had been finalized in the CY 2019 PFS. The proposed code will have a value of 0.61 RVU.

Finally, there is a proposal to revise the descriptor for HCPCS code GPC1X and eliminate HCPCS code GCG0X. The new descriptor for GPC1X Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established) is being updated to simplify the coding and, with the elimination of GCG0X, to remove the perception that the code is primary care or specialty specific. The value of GPC1X is also being increased to 0.33 RVU.

It must be made clear that these changes are proposals only, and CMS is still reviewing stakeholder and public comments. Any actual changes will not be codified until publication of the CY2020 PFS later this year. Additional information regarding the proposed rule can be found by accessing

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