AMA approves E M documentation changes

The AMA CPT Editorial Panel has approved revised guidelines for new and established office or outpatient visit codes CPT 99202-99215 that would eliminate history and examination as key components to select the E M service level. Additional E M documentation changes include the deletion of level one new outpatient visit code CPT 99201, and revisions to codes for prolonged services with or without patient contact.

Below are the major changes w.e.f Jan 1, 2021.

I. Accepted deletion of code CPT 99201

II. Revision of codes CPT 99202-99215 as follows: 

(A) removing history and examination as key components for selecting the level of E M service, but adding the requirement that a medically appropriate history and/or examination must be performed in order to report codes CPT 99202-99215; 

(B) making the basis for code selection either the level of medical decision making (MDM) performed or the total time spent performing the service on the day of the encounter; 

(C) changing the definition of the time element associated with codes CPT 99202-99215 from typical face-to-face time to total time spent on the day of the encounter, and changing the amount of time associated with each code; revision of the MDM elements associated with codes CPT 99202-99215 as follows: 

(i) revising “Number of Diagnoses or Management Options” to “Number and Complexity of Problems Addressed”; 
(ii) revising “Amount and/or Complexity of Data to be Reviewed” to “Amount and/or Complexity of Data to be Reviewed and Analyzed”; and 
(iii) revising “Risk of Complications and/or Morbidity or Mortality” to “Risk of Complications and/or Morbidity or Mortality of Patient Management”; revision of the E/M guidelines by: 

(A) restructuring the guidelines into three sections: “Guidelines Common to All E/M Services”, “Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care and Home E M Services”, and “Guidelines for Office or Other Outpatient E M Services” to distinguish the new reporting guidelines for the Office or Other Outpatient Services codes CPT 99202-99215; 

(B) adding new guidelines that are applicable only to Office or Other Outpatient codes (CPT 99202-99215); adding a Summary of Guideline Differences table of the differences between the different sets of guidelines; 

(C) revised existing E M guidelines to ensure there is no conflicting information between the different sets of guidelines; 

(D) adding definitions of terms associated with the elements of MDM applicable to codes CPT 99202-99215; 

(E) adding a MDM table that is applicable to codes CPT 99202-99215; 

(F) defining total time associated with codes CPT 99202 – 99215; 

(G) adding guidelines for reporting time when more than one individual performs distinct parts of an E M service; revision of the Medical Decision Making table in the  Amount and/or Complexity of Data to be Reviewed and Analyzed column: 

(1) inserted a dash (-) after the asterisk in the asterisk definition, “* – Each unique test, order, or document may be summed if multiple,” to clarify this is the meaning of the asterisk and not an asterisked item itself; 

(2) for limited amount of data to be reviewed and analyzed (codes CPT 99203/99213), the parenthetical regarding the number of categories for which requirements must be met was revised to state, “…categories of tests and documents, or independent historian(s)” rather than “categories within tests, documents, or independent historian(s)”; and 

(3) removing the word “or” after each of the bulleted items for limited, moderate (codes CPT 99202/99214), and high (CPT 99205/99215) amount and/or complexity of data to be reviewed and analyzed

Prolonged Svcs With or Without Patient Contact

Accepted revision of codes CPT 99354, CPT 99355 to exclude reporting of Office and other Outpatient Services codes, and revision of CPT 99356 to include observation; revision of the prolonged services guidelines; addition of new code 99XXX to report prolonged office or other outpatient E M services.

For more information: https://www.ama-assn.org/system/files/2019-03/february-2019-summary-panel-actions.pdf