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.
Medical decision-making component
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.
2022 Changes to E&M Guidelines
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:
- CPT code 99201 has been removed and is no longer active.
- History and exam components are required but not used for code selection.
- Medical decision-making or total time is used for code selection.
- If the time is supporting a higher level than the medical decision-making, time may be used for code selection. If medical decision-making is supporting a higher level than time, then medical decision-making may be used for code selection.
- Time descriptions for each code increased.
- Total time includes face-to-face and non-face-to-face time personally spent by the physician. Time examples include but are not limited to:
- ~ Preparing to see the patient (review of tests).
- ~ Obtaining and/or reviewing the separately obtained history.
- ~ Ordering medications, tests or procedures.
- ~ Documenting clinical information in the electronic health record or other records.
- ~ Communicating with the patient, family and/or caregiver through an interpreter.
- ~ Time spent on causation or apportionment analysis.
- Total time does not include and is not limited to:
- ~Time spent in activities normally performed by clinical staff (i.e., time spent by nursing or other clinical staff collecting a patient’s history).
- ~Time spent on services that are separately reported or billed (i.e., WC164 reports, independent interpretation and reporting of test results).
- ~Time spent on a date other than the date of the encounter.
- Updates to medical decision-making elements:
- ~Number and complexity of problems addressed.
- ~Amount and/or complexity of data to be reviewed and analyzed.
- ~Risk of complications and/or morbidity or mortality.
- Updates to prolonged services:
- ~CPT codes 99354-99357 for face-to-face and CPT codes 99358-99359 for non-face-to-face prolonged services are no longer reported with the outpatient E&M services.
- ~Outpatient E&M services have one new CPT code for face-to-face and non-face-to-face prolonged services to be used only when the code selection is based on time. The new code is 99417.
- ~CPT code 99417 is for every15 minutes beyond the time associated with 99205 or 99215. Multiple units can be reported.
- Consultation codes will remain in effect for Colorado workers’ compensation as indicated by the CPT and Medicare 1997 E&M guidelines.
If you have any questions, Pinnacol’s provider medical billing auditors will be happy to assist you. Please call the Medical Payments Team and Payment Appeals department at 303.361.4940, email firstname.lastname@example.org or fax 303.361.5940.