New CPT Coding Guidelines For Evaluation And Management Services (EMS)

Introduction to CPT Coding Guidelines

The evaluation and management of patient visits is one of the core practices of family physicians that are able to reduce stress and maximize payment associated with audits. They do this by ensuring they properly document and code patient visits.

When it comes to CPT coding guidelines, evaluation and management are a core category used for billing. It is essential to know that most patient visits require Evaluation and Management code. There are various levels of evaluation and management codes, which can be determined by reviewing the documentation requirements for the specific type and complexity of the visit.

For example, Medicare allows healthcare providers to document revisions of any historical data, which is entered into the health record by ancillary staff instead; there is no need to re-enter medical data such as history and examinations for established patients. However, physicians can document changes in the related items, which have not altered since the last visit.

Basic Components of Evaluation and Management (E/M) Codes

The necessary components of E/M codes are:

Chief Complaint: This focuses on the patient encounter – usually in the own words of the patient. For example, a complaint of headaches or stomach upset.
History of Existing Disease: This is the description of any chief complaints. This includes location, duration, context, severity, quality, timing, associated signs, symptoms, and any other relevant modifying factors.
Symptom Review: Different questions are asked to recognize the current symptoms. These questions include general appearance and vital signs as well as the results of examinations done on the eyes, ears, nose, and throat. The symptom review of organ systems covers the cardiovascular, gastrointestinal, musculoskeletal, respiratory, genitourinary, neurological, endocrine, psychiatric, integumentary, lymphatic, hematologic, and immunologic systems.
Family and Social History: This focuses on previous diseases, injuries, operations, and treatments. The patient’s family history is checked to analyze the patient’s potential risks, focusing on diseases, hereditary health conditions, and medical events. The social history of the patient refers to an age-appropriate review of the activities of the patient, including living arrangements, sexual history, substance use, education, employment, etc.
Examinations: Another essential component of the E/M codes, services, and their levels are primarily on four types of examinations, which are problem-focused, expanded problem-focused, detailed examination, and comprehensive examination. A problem-focused examination is a limited examination of the patient. The expanded examination includes the analysis of the patient’s organ systems as well as other symptomatic areas of the body. The detailed examination, which is often called the extended examination, focuses on the affected body area, organ systems, and other areas of the body related to the illness. A comprehensive examination is a general multi-purpose examination of a single organ system.
Medical Decision Making: This is about the determination of a management option after establishing a diagnosis. Usually, there are four levels of medical decision making in which diagnoses are used to make the type of decision – based on data analysis and risk of complications. The four levels are straightforward, low complexity, moderate complexity, and high complexity.

EMS Guidelines

Documentation in health records is a day-to-day occurrence for most healthcare providers. The health or medical records enable them to communicate with treatment team members and monitor patient care over time. The health record can facilitate the assessment of the utilization of resources, quality of healthcare, and collection of data used for research.

Guidelines Common to All Evaluation and Management Services

When it comes to the evaluation and management services, the levels of the emergency department have different components such as time, which is not a descriptive component. It is not easy to establish accurate estimates of the time spent with the patient – face-to-face. You can use the time to select a code level in the outpatient or in-office services irrespective of coordination and counseling, which dominate the service.

You can also use the time to select any other levels of the Evaluation and Management services while coordinating the service. When you use the time to choose the accurate levels for evaluation and management services codes, service descriptors will define time. Regarding the evaluation and management services, it is essential to have a face-to-face encounter to apply these guidelines.

Time for office and outpatient services for coding purposes is the total time on the encounter date, which includes the face-to-face as well as non-face-to-face time, which is spent individually by the health provider on the day of the encounter. The time for different activities requires you to include time in operations performed by the clinical staff. The following actions equate to the time of professional healthcare providers.

Preparations to see the patient or examine the tests.
Obtaining patient history and reviewing it.
Performing medical examination in an appropriate way.
Counseling and educating the caregiver, patient, and family.
Ordering tests and other related activities.
Communication and discussion with other medical professionals.
Documentation of clinical information (via Electronic Health Records (EHR)).
Interpretation of results independently and providing results to the caregiver, patient, and family.

Services Reported Separately

You can separately report specific identifiable service or procedure, is performed on the date of evaluation and management services. The actual interpretation of diagnostic studies and tests during a patient encounter can’t lead you to determine the levels of evaluation and management services when reported separately.

The performance of a healthcare professional regarding diagnostic studies and tests for which specific CPT codes are accessible can be reported separately along with the appropriate evaluation and management code. The interpretation of the health professional about the diagnostic studies or tests with an identifiable signed documented reported independently. You can do this by using the appropriate CPT code.

Besides, if you have independently interpreted a study or test to manage the patient under the evaluation and management service, then you need to know that it is a significant part of the medical decision making. If you are a physician, then you may need to indicate the separately identifiable Evaluation and Management service based on service or procedure identified by a CPT code.

The symptoms or condition of the patient may cause or promote the Evaluation and Management service for which the service or procedure was provided. You can report this circumstance by adding modifier 25 to the appropriate level of Evaluation and Management service. You may not need different diagnoses to report the procedure on the same date.

Office and Outpatient Service Guidelines

Typically, office or outpatient evaluation and management services focus on the physical examination and appropriate medical history of the patient. When it comes to the nature of the “history” or “physical examination,” you – as a physician – determine them quickly.

Likewise, the care team can collect data and information, whereas the patient, caregiver, or family can supply information through a questionnaire or portal, which is evaluated by the reporting health provider or any other qualified medical professional. Besides, the extent of the medical history and physical examination is not used to select the office or any outpatient service.

The complexity of problems, at an encounter, is one specific element, which helps you select the level of code for an office or outpatient service. You can also address established or multiple new conditions simultaneously. This complexity will affect your medical decision making. A specific diagnosis is based on symptoms, which means that a unique health condition is not a symptom itself.

You can’t select a level of evaluation and management service based on comorbidities or underlying diseases, but this occurrence of any underlying condition increases the complexity of information. Besides, the data requires review and analysis to measure the rate of morbidity and mortality of patient management.

The complexity or risk cannot determine the final diagnoses of a particular disease or health ailment, because you need an extensive evaluation to conclude, that the signs and symptoms do not represent a highly morbid condition. So much so, multiple issues of a lower severity can create higher risks – due to interaction.

A Guide to Problems

What is the problem?

A problem is a health condition, disease, injury, illness, sign, symptom, complaint, or findings. It addresses the matter at the encounter – without establishing diagnoses at the time of the encounter with the patient.

How to address a problem?

You can address or manage a problem only when you have assessed or treated it during the encounter with the patient. What does this include? Well, it takes into consideration the testing and treatment, which might not be elected by risk-benefit analysis or the choice of patient, guardian, or surrogate.

Notation in the medical record of the patient that another physician is handling the problem without care coordination or additional assessment documented – can’t be declared as “addressed” by the health professional who reports the service. Treatment consideration also can’t be considered as being addressed by the health professional.

What is a minimal problem?

You can refer to CPT code 99211 to fully understand the minimal problem. It does not require the presence of a health professional. Similarly, another important aspect that you need to understand is “self-limited or minor problem,” which runs a prescribed and definite course that can’t change the health status permanently – although it is transient.

Stable and Chronic Health Conditions

A “stable” or chronic health condition refers to a problem, which has an expected duration. According to the guidelines, this can be for at least a year and until the patient’s death. When we define chronicity as per the guidelines or standards, diseases, and disorders are considered chronic based on the changes of severity. For example, controlled or uncontrolled diabetes is regarded as a single chronic health condition.

Similarly, when defining the stability, it refers to the categorization of medical decision making, which is characterized by a specific treatment objective for the patient. For example, a patient with no treatment objective is unstable – even if there are no changes in the health condition, or there is no short-term threat to functioning or life.

If a patient has a poorly controlled hypertension persistently with no better control, then it is not stable – even if the levels of hypertension are not altering and the patient is asymptomatic. It is essential to take into consideration the risk of morbidity without treatment. For example, this may include non-insulin dependent diabetes, well-controlled blood pressure, benign prostatic hyperplasia, or cataract.

Acute, uncomplicated illness or injury

“Acute” or uncomplicated disease or injury is a new short-term problem with lower risks of morbidity, which takes into account the consideration of the treatment. When it comes to the procedure, there is no risk of mortality – so, you – as a physician – can expect full recovery with any functional impairment. An uncomplicated acute illness is a problem, which is minor or self-limited. However, the problem is not resolving with a prescribed course. For example, a simple sprain, allergic rhinitis, or cystitis.

Chronic illness with exacerbation, and side effects of treatment

Chronic disease with exacerbation refers to the progression, poorly controlled, or worsening condition with a strong intent to control the disease progression. It requires additional care along with treatment to control side effects. Nonetheless, it does not require attention at the hospital level.

Undiagnosed new problem with an uncertain prognosis

In the differential diagnoses, it is a problem representing a particular health condition, which can result in higher morbidity risks without treatment. For example, a lump in the breast.

Acute illness with systemic symptoms

It is a health condition or disease, which leads to systemic manifestations. It has higher risks of morbidity without treatment. For example, health conditions such as body aches, fever, and fatigue are considered minor illnesses, which the physician can treat to alleviate symptoms as well as to prevent any complications related to the disease, or shorten the course of the health condition.

Moreover, this is also about seeing the definitions “acute, uncomplicated,” or “self-limited or minor.” Systemic symptoms can be a single system – for example, colitis, pneumonitis, and pyelonephritis.

Acute, complicated injury

An acute or complicated injury usually requires treatment – including assessment of the patient’s body systems, which are part of the injured organ directly. It also refers to the extensive trauma. Likewise, the new CPT guidelines show that it can also be the treatment option that is associated with the risks of morbidity. Besides, one of the examples of acute, complicated injury is a head injury, which has a loss of consciousness.

Chronic illness with severe progression and side effects with treatment

The progress of a health condition at the “chronic level,” which may require care at the hospital level. In other words, it is a chronic disorder, the treatment of which can only be done at the hospital.

Acute or chronic injury or illness that poses a threat to bodily function or life

It is a problem with a complicated acute injury, or systemic symptoms, or chronic injury or disease with side effects of the treatment or progression of the disease, which poses a threat to the bodily function or life of the patient in the near term. Examples include changes in neurological status, acute renal failure, peritonitis, psychological illness, rheumatoid arthritis, respiratory distress, pulmonary embolus, and acute myocardial infarction.

Tests

Tests refer to the laboratory, imaging, physiologic, or psychometric data. According to CPT guidelines 80047, a clinical laboratory panel – for instance, the basic metabolic panel is a single test. The CPT code set defines the difference between single or multiple unique tests.

External

These are defined as external records, discussions, communications, or the results of tests, which are carried out by an external healthcare provider, a qualified physician, or a healthcare organization. This includes health professionals with licenses or qualified physicians who practice independently. It can also be a healthcare organization – i.e., a hospital, home health care agency, or nursing facility.

Streamlining Evaluation and Management Payment

Around two decades ago, the Centers for Medicare and Medicaid Services or CMS introduced guidelines for documentation related to the evaluation and management services. The CMS published an updated version of the “guidelines” in 1997 – which differed mostly in documentation requirements associated with the examination of the physician.

Criteria outlined in these guidelines were felt to be acknowledgeable for billing Medicare – while assuming to meeting that specific criterion. Moreover, in most situations, this included various reasons for the encounters, a relevant history, findings from the physical examination, results of the diagnostic tests, assessments, as well as care plans. Today, there are various beliefs about documentation in which the main one is to comply mainly with the requirements of coding.

It is essential to know that the time required for compliance can be significant, which likewise can limit the opportunity to address the needs and care of the patient adequately. It is relatively common for health professionals to dedicate a substantial portion of their workday to the process of documentation. This alone is a crucial contributor to health professional burnout and dissatisfaction.

Furthermore, electronic health records or EHR systems have a wide range of advantages, which include the capability of surfacing relevant clinical data at the point of care. However, when documenting in the EHR, health professionals can use templates to ensure meeting the requirements of billing.

So much so, notes generated using this strategy can be excessively comprehensive and lengthy – at the same time, they can be very hard. Therefore, these notes actually won’t facilitate effective communication. Instead, they run the threats of burying healthcare impressions and recommendations at the clinical level – especially, undermining coordination of care.

To solve these issues, CMS has introduced new CPT codes intending to decrease administrative burdens, improving the beneficiary experience, and increasing overall efficiency.

The primary objective is to simplify the requirements of the documentation – leaving health professionals more significant time to spend with their patients as well as focus on specific things, which had changed or altered since the last visit. The new guidelines are increasingly focusing on team-based care to minimize documentation, which is redundant – so, the focus is to apply standards that are driven by medical decision-making.

Although the CMS has been given relatively uniform praise for its commitment to streamline and minimize the requirements for documentation regarding the evaluation and management visits, there are many concerns raised – especially about the financial implications of a payment rate for the level 2-4 “visit” among healthcare professionals who see patients that require complex care.

The blended payment rate equates to the level of 3.45 visits for established patients and 3.35 visits for new patients. Healthcare professionals who have billed historically for a greater number of level-two and level-three visits will see increased payments – those who have billed for level-four visits will likewise see a decreased payment.

Furthermore, the new policy by the CMS will maintain the neutrality of the payment as it won’t take into consideration the fact that the distribution of a billed visit may not be bell-shaped within a specific specialty. For example, in cardiology, greater patient complexity, as well as high burden of comorbid conditions, account for a distribution of the evaluation and management visits, which are skewed rightward, with greater level-four than level-two visits.

Consequently, CMS is projecting a two percent net reduction in payments to healthcare professionals who deal with cardiovascular diseases. At present, there is no indication of specific subspecialties within the cardiology, which are more likely to be affected. Health care professionals who spend a much greater percentage of time in office or outpatient setting to care for complex patients are likely to see a much greater impact.

Currently, uncertainty exists about these changes and whether or not they will be endorsed or adopted by the commercial payers. For example, previously, the policy related to coding by the CMS was not adapted – i.e., 2-midnight rule. Besides, acceptance of CMS policy will certainly simplify the evaluation and management coding but at the expense of a reduction in reimbursement for healthcare professionals.

On the other hand, failure to adopt the policy by various commercial payers can necessitate healthcare professionals either having to navigate two different evaluation and management documentation protocols/standards or choosing one standard, which can be applied more broadly. With the latter approach, healthcare professionals can see an even more significant decrease in payments if the documentation standard, which is based on level-two requirements, is applied to patients who are insured by commercial payers.

Moreover, this would further reduce face-to-face time with patients. Shorter visits have a high potential to decrease the satisfaction of both the health provider and the patient, which likewise leads to lessening the time for education and counseling. As a result, there is a lower quality interaction.

Furthermore, shorter visits can encourage much greater use of documentation templates that could perpetuate the “note bloat.” For those patients who require complex care needs, shorter encounters will result in frequent office visits, overall greater inconvenience, and a significant spend on copayments annually.

The coding structure by Centers for Medicare and Medicaid has been finalized for 2021 – still, changes could be made in rulemaking in the future. Before the release of the rules, the CPT Editorial Panel, the American Medical Association, and a coalition of professional health societies encouraged CMS to depend on the AMA workgroup to address the complicated problems related to coding, documentation, and payment.

While finalizing the changes for 2021, the CMS notes that a two-year delay in the plan implementation will allow them to respond accurately to work done by AMA and CPT Editorial Panel. The CMS will consider specific changes, which are made to CPT coding for evaluation and management series. They will also take into account the recommendations for the appropriate valuation of revised or new codes.

Changes to Evaluation and Management Services

All those people who are involved in coding and compliance that “Centers for Medicare and Medicaid Services” CMS and “American Medical Association” AMA have introduced changes in the evaluation and management services.

Do you have the choice to use the other guideline (1995 AND 1997 guideline)? This is an important question, which needs to be addressed. Since the new changes will take effect from 2021, healthcare providers can use the previous guidelines (1995 and 1997).

However, can you – as a health professional – use these guidelines after the new CPT codes are fully operational? The answer to this question is “Yes,” you can use them as long as they coincide with the new CPT guidelines and do not affect the patient and his or her health condition.

However, the AMA, CMS, and other concerned authorities recently realized the importance of making changes in the evaluation and management services after the advent of EHR software and applications.

So, this coincides with the idea that if all elements of the data were met, then the service would be reimbursed naturally. No one talked to the health professionals creating evaluation and management documents in order to comprehend its actual purpose – i.e., to document the provided care, the response of the patient to provided care, as well as care planning and changes.

Recently, CMS has become friendlier when it comes to the provision of healthcare. This is why they have introduced several changes to decrease health professionals’ administrative burden and tool back some rigid requirements. The panel members of AMA recently approved revisions of the evaluation and management CPT office and outpatient visit reporting code descriptors.

According to AMA, this decision was in direct response to CMS leadership that sought revisions to the previous evaluation and management rules – in order to make them friendlier – the purpose of which is to reduce burnout.

Analysis of the Conference Call – August 12, 2019

CMS seemed to be in the lock-step with the proposals of the AMA. During the conference call in August 2019, CMS repeated their concerns and worries about the evaluation and management services. In the CY 2019 PFS Final Rule, CMS finalized two add-on G codes of the HCPCS, which describe additional resources that are associated with the primary care and specific types of non-procedural visits. This was for CY 2021.

CMS has focused on ongoing engagement and interaction with stakeholders, and the primary emphasis is on the add-on code or codes, which must be easy to understand and report for specific purposes of health documentation and billing.

CMS also wanted to maintain clarity regarding the add-on code, which is not intended for reflecting differences in the payment by specialty. However, it is about recognizing differences in per visit resource and its cost, which is based on the type of care provided by the clinician – notwithstanding the Medicare enrollment specialty.

This is why CMS proposed a single add-on code, which defines and explains the ongoing primary care related to a single, complex, or serious chronic condition billable with any office or outpatient evaluation and management visit meeting these criteria.

The Plan of the American Medical Association (AMA)

The plan of AMA is focused on making a revision to the evaluation and management office and outpatient visits – i.e., causing changes in the CPT codes 99201 to 99215. In 2021, the revised code set will be effective. The AMA likewise believe that these changes will be in step with the CMS evaluation and management, which are established in 2019 that include:

Eliminating the requirement for documentation for the medical necessity that focuses on furnishing visits in the home instead of the office.
Eliminating the requirements for healthcare professionals to re-record medical elements for history and physical examinations when there is proof that the data or information has been evaluated and updated.
Healthcare professionals such as physicians must only document reviewed or verified information about the chief complaint as well as history, which are already recorded by the patient or ancillary staff.
The AMA will commission a research study of peer-reviewed and evidence-based literature to identify the amount of time, which can be saved reasonably once these evaluation and management visits are implemented. For instance, assume a conservative decrease of 2.11 minutes per visit, a health professional who sees 20 patients a day could have 180 hours of freed time in order to focus on patient care.
The reduction of the additional burden will be observed by simplifying the selection criteria for code and making them clinically relevant and intuitive.
Establishing consistency by adding details within the CPT evaluation and management guidelines.
Aligning current guidelines for documentation from Medicare as well as the CPT code set to make sure minimal practice disruptions.

Revisions

The work of the healthcare professional in capturing the pertinent history of the patient’s history and performing a physical examination largely contributes to time and decision-making. Therefore, these elements must not determine the code level alone. The code descriptors are revised by the workgroup to state providers must perform an appropriate medical history or examination. Physicians are allowed to choose whether the documentation is based on total time or medical decision-making.

In addition, the workgroup didn’t change the three current medical decision-making sub-components. However, it did provide edits extensively to the elements for the selection of code and created various definitions in the evaluation and management guidelines. Moreover, when it comes to time, the definition refers to the minimum time and not the typical time. It also represents total qualified health professional time on the service date.

The use of service-date time creates on the movement over the last couple of years by Medicare to recognize – in a better way – the work, which is involved in non-face-to-face medical services like care coordination. The definitions can only be applied when the selection of the code is mainly based on time and not on medical decision-making.

As far as modifications to the criteria for medical decision-making are concerned, the panel used the existing CMS “Risk Table” as a base – particularly, to design the revised required elements for medical decision-making. Current audit tools by the CMS were also consulted to reduce disruptions in the medical decision-making level criteria.

AMA also focused on removing ambiguous terms such as “mild” and defined concepts that were previously ambiguous – for example, “acute or chronic disorder with systemic symptoms.” AMA also defined other important terms like “Independent historian” as well as re-defined the elements of data to move away from adding up tasks to focusing more on tasks, which affect patient management. For example, an independent interpretation of a particular test, which is performed by another health provider.

Moreover, AMA planned to delete the CPT code 99201 – and the panel agreed to remove 99201 because of it is straightforward medical decision-making, which can only be differentiated by the patient’s history and examination elements. The panel likewise agreed on shortening prolonged services code, which would capture the health professional time in 15 minutes increment. This code will only be reported with the CPT code 99205 and 99215. Similarly, it can be used when the code selection is made primarily on the basis of time.

Conclusion

We are happy to see that AMA and CMS rule makers have realized their work because the absent healthcare professional input won’t stand the test of time. During the conference, CMS mentioned that ten thousand new beneficiaries are added on an everyday basis, while fewer health professionals are available for providing care to them.

Therefore, the revisions to evaluation and management, as well as the new reimbursement categories, can improve those ratios. Quality health care can’t be promoted by adding more patients and driving health professionals out of practice.

The revisions by AMA and CMS make an absolute sense – particularly, they will enforce changes in the evaluation and management formats in the electronic health records. More interestingly, we are ready to see how the electronic health record format is changed to accommodate the alterations and how much will this actually cost. So, most physicians or healthcare experts say that the revision won’t save the time of the healthcare provider unless this modification happens.

Moreover, there is a need for the establishment of new formats in order to mirror the evaluation and management requirements instead of claiming forms. Otherwise, the “note bloat” will be there, and the revisions won’t yield more improvement for the health providers. Most physicians do wonder about the calculation of time. Again, the definition of time, according to the new CPT guidelines, is “minimum time,” and not the “typical time.” So, this represents the total time on the date of service for a physician or qualified health professional.

What does this mean? If the health providers use an onerous electronic health record and stay late in the office for the completion of their notes on the DOS on which the patient was seen – does this element into the “time” determination? Physicians understand the establishment of care and management plans – notably, they do this in reaction to the recently proposed CMS plan to require healthcare plans for patients who have one chronic illness rather than a minimum of three.

Furthermore, these tasks usually don’t require the patient’s presence. However, is there any way to determine the time spent in this particular task as compared to the clinical patient time? This is the question of concern posed by many health professionals, and they expect the AMA and CMS to propose something that focuses on healthcare providers to spend more time with the patient and address his or her particular disease.

However, if this does not happen, will patients see their health provider’s face again or wait for the provider until he or she populate their electronic health records. To clarify this issue, the CMS has proposed G-codes, which might be useful in resolving this problem. For many health professionals, it would be interesting to see the proposal for the CPT changes to the calculation of medical decision-making. Again, they are removing various descriptors, which seems a good improvement.

Lastly, we are glad to see the AMA and CMS have proposed the prolonged time, which can be counted in 15 minutes’ intervals. This actually is a much better representation of the health provider’s time – mainly since most office visits will take fewer than 15 face-to-face minutes.

New CPT Coding Guidelines for Evaluation and Management Services (EMS)

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