The evaluation and management (E/M) changes for calendar year 2021 are the result of a collaborative effort between the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS).
CMS first addressed the changes in the 2020 Medicare Physician Fee Schedule Final Rule, in which CMS indicated that it planned on adopting the AMA's code revisions and accompanying guideline changes for the E/M office or outpatient visit codes.
In this year's MPFS proposed rule, CMS addressed the E/M RVU changes, the proposal to create a visit complexity add-on code, and its agreement with the AMA changes that will be implemented January 1, 2021.
Here is a summary of the E/M changes:
• The level 1 new patient office or outpatient visit code, CPT® code 99201, will be deleted.
• Medical decision-making or time, as redefined by the AMA, will determine the E/M level selection—history and exam will no longer count as key components in level selection.
• When time is the determining factor, that time will be based on the total time of the visit rather than on typical face-to-face time.
• Each level of office or other outpatient visit will have a separate payment amount.
• CMS will recognize the new prolonged service code, CPT code 99417. CPT codes 99358 and 99359 will be payable when reported with an office or other outpatient visit code.
In theory, shifting level selection to time and medical decision-making should be easy. However, healthcare physicians and practitioners are heavily used to the previous guidelines, specifically with regard to the key components and typically associated times for various visit levels. Now these same well-schooled practitioners face the new AMA framework.
Healthcare practitioners will need to familiarize themselves with a new medical decision-making table as well as a new definition of "time" for office or outpatient visit services. Time, as redefined, now encompasses the practitioner's total time spent on services during the day of the visit, including both face-to-face and non-face-to-face time. It will include time spent preparing to see the patient, counseling the patient and/or family, coordinating care, and documenting in the medical record. Practitioners will also need to be mindful that these new guidelines only apply to the office or outpatient visit CPT codes. Outside of these sites of service, practitioners will still determine the E/M level based on the established 1995 and 1997 guidelines, and code-specific CPT guidelines.
Also, remember that in the 2020 MPFS final rule, CMS finalized a new add-on HCPCS code with an effective date of January 1, 2021, to recognize additional resource costs that are inherent in furnishing primary care and certain types of specialty visits. The code, referred to as "GPCX1" and not numbered as of yet, was finalized with the description below:
GPCX1 - 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.)
CMS’ continued commitment to patient access and acceptance of the role technology plays in the delivery of such patient services is apparent in the 2019 Medicare Physician Fee Schedule final rule. The agency has finalized its proposal to begin reimbursement of two newly defined physicians’ services using communication technology. The ability to utilize and submit these new HCPCS level II codes benefits patients, insurers, and providers through convenience and cost savings.
The two newly defined physicians’ services are:
Brief communication technology-based service (e.g., virtual check-in) (G2012)
Remote evaluation of recorded video and/or images submitted by an established patient (G2010)
Although these services resemble telehealth, CMS clearly indicates that the services are not considered Medicare telehealth services; therefore, they are not subject to the geographic and other restrictions on telehealth services under section 1834(m) of the Social Security Act.
The creation and finalization of HCPCS G2012 allows for separate reimbursement of the brief communication technology-based patient check-in with the physician to determine the necessity of an office visit or other service. The ability for the patient to confer with the physician prior to the office visit increases efficiency for healthcare providers and convenience for patients.
For G2012 to be considered a reimbursable service, healthcare providers must meet the following
requirements:
Virtual check-in must be reasonable and medically necessary.
The service can only be provided to an established patient of the provider.
Given that there is a cost-sharing for the beneficiary due to coinsurance, the patient must give verbal consent for the service, and the consent must be documented in the medical record for each time the service is provided.
Only a provider who can report an evaluation and management (E/M) service can bill for this service (i.e., communications between patient and clinical staff are not billable).
The virtual check-in cannot relate to an E/M service, meaning the communication cannot be related to an E/M visit provided to the patient in the last seven days or result in an E/M visit in the next 24 hours (or soonest available).
Modalities permitted include real-time audio-only telephone interactions in addition to synchronous or two-way audio interactions that are enhanced with video or other kinds of data transmission. The final rule clearly stated that communications by email, text, or voicemail (exclusively) will not be reimbursed.
For G2010 to be considered a reimbursable service, healthcare providers must meet the following requirements:
The service must be reasonable and medically necessary.
The service can only be provided to an established patient of the provider.
Given that there is a cost-sharing for the beneficiary due to coinsurance, the patient must give verbal consent for the service, and the consent must be documented in the medical record for each time the service is provided.
