Significant changes were made to the Current Procedural Terminology® (CPT) codes for outpatient evaluation and management (E&M) in 2021. E&M levels will be determined by total time or medical decision-making. The Division of Workers’ Compensation (DOWC) will follow CPT guidelines as well as Exhibit 1 to help determine the level of service that should be reported. These changes will be effective for Rule 18 Jan. 1, 2022.
New patient E&M codes (99202-99205) and established patient E&M codes (99212-99215) no longer require the three components or time for counseling and coordination of care. Instead, a medically appropriate history and examination are required, but the code selection is determined by the level of the medical decision-making or total time spent on the day of the encounter date. The number of minutes required for each code has increased as well.
The physician may select the code based on the highest component documented (time or medical decision-making). If the time documentation is supporting a higher level than the medical decision-making, then time can be used for code selection and vice versa.
Time descriptions and the number of minutes for each code have increased for the total time component. Total time includes the time spent on the day of the encounter for services that are not separately reported. Time includes prepping for the visit, documentation and face-to-face time with the patient. However, the time does not include activities normally performed by clinical staff.
The four levels of medical decision-making remain the same: straightforward (CPT codes 99212 and 99202), low (CPT codes 99213 and 99203), moderate (CPT codes 99214 and 99204) and high (CPT codes 99215 and 99205).
Medical decision-making is defined by three elements: the number and complexity of problems addressed at the encounter, the amount and complexity of data, and the risk of complications. Problems are defined as a disease, condition, illness, injury, symptom, sign, finding, complaint or other matter addressed at the time of encounter, with or without a diagnosis being established. Data is every unique test, order or medical record reviewed or obtained for the visit. Risk is the patient’s possibility of complications, morbidity or mortality. If time is not used, the amount and complexity of the problems, data and risk determine the level of the visit.
The DOWC sets the billing requirements and the maximum allowable fee schedule. Rule 18 states CPT codes are based on the code set for the prior year, and the relative value of each code is based on RBRVS using the Medicare standard from the prior year. For workers’ compensation in 2022, the code set to be used for billing is from 2021; therefore, the 2022 CPT outpatient E&M changes will be in effect and are summarized below:
Please call the Medical Payments Team and Payment Appeals department at 303.361.4940 or email billingsuccess@pinnacol.com