2021 Proposed Changes for Evaluation and Management Services

By Marie Franklin, MBA, National  Director of Coding, Education, and Audit

The proposed new rules for 2021 will focus on medical decision-making or time as the determining factor when selecting the appropriate level for service rendered for all physicians for evaluation and management. Currently, Medicare has not made Medical Decision Making (MDM) as one of the determining components for establishing and/or subsequent visits. Currently, the coders are focused on using the approved Medicare E & M tool to determine the appropriate level based on supporting documentation. Coding will need to modify the process to consider the presenting problem as it relates to the medical necessity of the patient’s care. The key is to ensure that the presenting problem is supported in the medical record and the services provided were a medical necessity to care for the patient’s condition. The providers will need to begin to document the “why” to support medical necessity.

Proposed Revisions

1. Eliminate history and physical as elements for code section: While the physician’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.
   1. The Workgroup revised the code descriptors to state providers should perform a “medically appropriate history and/or examination.”
2. Allow the physician to choose whether their documentation is based on Medical Decision Making (MDM) or Total Time
   1. MDM: The Workgroup did not materially change the three current MDM sub-components, but did provide extensive edits to the elements for code selection and revised/created numerous clarifying definitions in the E/M guidelines. (See below for additional discussion.)
   2. Time: The definition of time is minimum time, not typical time, and represents total physician/qualified health care professional (QHP) time on the date of service. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services like care coordination. These definitions only apply when code selection is primarily based on time and not MDM
3. Modifications to the criteria for MDM: The Panel used the current CMS Table of Risk as a foundation for designing the revised required elements for MDM. Current CMS Contractor audit tools were also consulted to minimize disruption in MDM level criteria
   1. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g. “acute or chronic illness with systemic symptoms”)
   2. It also defined important terms, such as “Independent historian.”
   3. Re-defined the data element to move away from simply adding up tasks to focusing on tasks that affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with an external physician/QHP)
4. Deletion of CPT code 99201:The Panel agreed to eliminate 99201 as 99201 and 99202 are both straightforward MDM and only differentiated by history and exam elements
5. Creation of a shorter Prolonged Services code: The Panel created a shorter prolonged services code that would capture physician/QHP time in 15-minute increments. This code would only be reported with 99205 and 99215 and used when time was the primary basis for code selection”

Marie Franklin is the National Director of Coding, Education, and Audit, a vital healthcare professional at AdvantEdge Healthcare Solutions with over 23 years of coding experience. 

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