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Understanding Why 99201 Will be Deleted

A look at the proposed Medicare Physician Fee Schedule.

As you may be aware, the proposed Medicare Physician Fee Schedule (MPFS) rule for 2020 was officially published on Aug. 14, 2019. 

There are many components to the rule, including a proposed change in the PFS conversion factor to $36.09, the addition of several new HCPCS codes for bundled episode-of-care treatment for opioid use disorders, modification of physician supervision requirements for physician assistants, and changes to permit the review and verification of clinical documentation made by other physicians, residents, nurses, students, or other members of the medical team. Some of the most substantive changes involve the documentation and payment for evaluation and management (E&M) coding – in particular, new patient visits and established patient visits.

E&M services represent approximately 40 percent of the allowed charges for PFS services. Office/outpatient E&M services represent nearly 20 percent of all allowed charges paid for professional services. But much as changed since the MPFS Final Rule for 2019.  

The American Medical Association (AMA) went to work and created the AMA CPT® Workgroup on Evaluation and Management Codes. This workgroup created an alternative approach to the structure of the Centers for Medicare & Medicaid Services (CMS) reported in the MPFS Final Rule for 2019. Based on this work, the summary of recommendations was officially adopted by the AMA in April 2019 and is set to be implemented for CPT effective Jan. 1, 2021. But the story gets better.

CMS has also reviewed the work of the AMA CPT Workgroup and has found the majority of the changes to their liking, and it has submitted these changes in the 2020 Proposed Rule. So here is a summary of the proposed E&M code changes for new patient visits and established patient visits, to be effective Jan. 1, 2021: 

  • 99201 will be deleted – the reasoning is based on the fact that both 99201 and 99202 are associated with straightforward medical decision-making.
  • History and physical examination will no longer be parameters for level-of-service selection. The provider will still be responsible for documenting the appropriate and medically necessary history and physical examination information, but these portions of the documentation will not be considered when determining the level of service.
  • Medical decision-making or time will be the determining factor in level-of-service selection. But the proposed definition of time is different – including the total face-to-face and non-face-to-face time spent involved in patient care activities including:
    1. Preparing to see the patient (review of test results)
    2. Obtaining and/or reviewing separately obtained history
    3. Performing a medically appropriate examination and/or evaluation
    4. Counseling and educating the patient/family/caregiver
    5. Ordering medications, tests, or procedures
    6. Referring and communicating with other healthcare professionals (when not separately reported)
    7. Documenting clinical information in the electronic or other health records
    8. Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
    9. Care coordination (not separately reported)
  • Medical decision-making (MDM) proposed changes resemble a reconfiguration of the three MDM sections into the format of the Risk Table, with some notable improvements:
    1. Each unique test, order, or document counts – meaning that instead of multiple lab or radiology or medical tests simply counting as one item in that category, each unique test counts toward the overall volume, for both reviewing and ordering.
    2. The decision for hospitalization has been acknowledged in the risk category.
    3. Definitions have been provided for the elements listed in the revised MDM table for greater clarity.
  • Visits will keep differentiation, including levels 2-5for new patient visits and levels 1-5 for established patient visits – each with its own payment rate – so no more level 2 minimal documentation parameters or the same level of payment for levels 2-4.
  • There will be the creation of a prolonged services code (99XXX), for use only with office/outpatient E&M visits. This is a time-based billing code and can only be used to represent time beyond the highest E&M code in the appropriate code set. This means that to use 99XXX for a new office or outpatient hospital visit, the time must surpass the time requirement for 99205. (This code’s description will support use in 15-minute intervals and will be available for use only with CPT codes 99205 and 99215.) The proposed wRVU is 0.61.
  • HCPCS GPC1X description will be revised to support utilization as an add-on code to describe the additional work and resource costs associated with the ongoing care of single, serious, or complex chronic conditions. Still at issue with this HCPCS code is what that really means. The proposed wRVU is 0.33.
  • Work relative value units (RVUs) are proposed to increase on more than 75 percent of the nine codes remaining in these two code sets (99202-99205 and 99211-99215) and the remaining codes wRVUs are staying the same.

So now is the time to read the proposed CMS changes and read the work done by the AMA. There is still work to be done, so make comments on the proposed changes. 

Let your voice be heard!

Programming Note:

Listen to Sally Streiber report this story live during Talk Ten Tuesday today, 10-10:30 a.m. EST.

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Sally Streiber, BS, MBA, CPC, CEMA

Sally Streiber received her MBA from Cleveland State University.   She is a certified professional coder and serves as the Director of Provider Compliance for a major Ohio health system. Sally and her team are responsible for Compliance and Ethics related activity for over 2,700 employed providers in the health system.

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