Good afternoon and welcome. Today, we are going to talk about the new requirements for evaluation and management codes that took effect on January 1st. I'm Erica Miller, Senior Vice President and Counsel with CRD Associates and work with the AASLD Public Policy Committee. CMS, the Centers for Medicare and Medicaid Services, has spent a number of years refining their E&M code policy, and so there were a number of changes that took effect on the 1st of this year, January 1st, 2021. Today, we want to spend some time talking about three different pieces of the policy, the changes to the outpatient E&M code family themselves, the new values for these services, and then also the revised documentation requirements that were implemented as well. Just very quickly, how did we get here? How did we get to all of these very significant changes being made? Well, back in 2018, the Centers for Medicare and Medicaid Services, CMS, had proposed very significant changes to the outpatient E&M code family. These were the first major changes that were made to the code since they were placed on the Medicare Physician Fee Schedule, and the House of Medicine was united in their opposition to these changes, which would have collapsed the code set and created a single payment level for the codes while they were also simplifying the documentation requirements. So then, in response, the AMA-CPT editorial panel got involved, and they actually revised the outpatient code family. They made some changes to the codes in the family themselves, but most significantly reworked the outdated 1995-97 guidelines. So then, after CPT approved the revisions to the code family, then they went to the AMA RUC to value them. The revised code family and the revised values were sent to CMS, which the agency accepted these new code descriptors and values as recommended, and then finalized them for implementation of January 1st of this year, 2021, in the 2020 Physician Fee Schedule. That gave everyone a year to get prepared for the change, and then also left the agency with another year to make some changes if they wanted in rulemaking, and that rulemaking concluded in December of 2020. However, what CMS did resulted in actually the values of the majority of codes on the fee schedule decreasing because of a decrease in the conversion factor, and we'll talk more about that later. And so then Congress stepped in, and they actually made some changes in their end-of-year package to what was going on with the outpatient E&M code family. So this presentation today reflects the changes that Congress made in the Consolidated Appropriations Act that passed in late December and was signed into law. So just an overview of the changes. So the first, as I mentioned, there were changes in the valuation for the whole code family, and the new patient Level 1 code was eliminated by CPT. A new add-on code was developed for when you're billing a Level 5 service by time, and you exceed the time threshold for that service. What happened was CPT created a new code, which is 99417. CMS stepped in and disagreed with some of how that code descriptor was worded, and they actually created a new add-on code for the Medicare population, G2212, and we'll talk about that in more detail later. And then again, the major changes to documentation. Now you can bill all of the outpatient E&M codes by medical decision-making or time, and that's how you're going to select your code level. You no longer are required to do a history or physical exam. And then when you're billing by time, time will include all of the practitioner time on the calendar day of the visit. So that's any time you spend in preparation for the visit, the visit itself, and then any additional time on that same calendar day after the visit. And again, we'll talk about these changes in more detail. So let's look at the changes to the code family in more detail first. So as I mentioned, you can see that 99201 has been eliminated. That was one of the major changes made by CPT, and they created that time-based add-on code 99417. CMS then stepped in and created two add-on codes, G2211, to recognize additional complexity for certain E&M visits. And this is a code that actually Congress stepped in and delayed. You may have heard about this code and potentially were preparing to use it, but based on the actions of Congress, it's not going to be available until 2024. And then CMS created that, as I mentioned, G2212 for additional time above a level five visit when you're billing by time. And again, there's this G code, G2212, when you're seeing Medicare patients, and then there is the actual CPT code 99417 that's available for patients with private insurance or not Medicare. So let's talk about this complexity add-on code a bit. So CMS had not felt that the revised code family actually reflected all of the work of certain types of E&M care. They thought there were resources that were included in a primary care or certain other specialty care visits that were not reflected. And so they had created this add-on code that could be billed with all outpatient E&M visits for new and established patients whenever an E&M was billed. And so we had anticipated that there will be very high utilization by hepatologists, but then ultimately Congress stepped in and they delayed the implementation of this code, which I mentioned had a moratorium on its implementation. A lot of the concern about this code was that it was not well-defined. And in conversations with Congress, they feel that this moratorium will allow CMS to better define this work and reflect it in this code or a different code. But ultimately, the decision to delay was really one that came down to money. The E&M code changes were going to result, as I mentioned, to a significant change in the conversion factor. And by delaying the implementation of this code, that was one way for CMS to raise the conversion factor. And we'll look at this in more detail. But again, you might have been preparing to build this code and it is no longer available to you. So let's look at the other add-on code. And so this is, as I mentioned, two codes. If you're seeing Medicare patients, G2212. And if you're seeing non-Medicare patients, it's 99417. So this add-on code is only available when you are billing a Level 5 outpatient visit by time. So again, remember, you're now going to have a choice to document by time or medical decision-making. So if you are billing by time and you exceed the upper-level limit of a Level 5 visit by 15 minutes or any additional 15-minute increments, then you can bill this code. So the upper-level time for a new patient is 74 minutes. And then for an established patient, it's 54 minutes. So if you were to see a new patient for 89 minutes, you would be able to bill this code once. If you then were to spend more than half an hour above that 74 minutes, so 104 minutes, you could actually bill this code twice. So you can bill it for each 15-minute, full 15-minute increment above that maximum time. And so it's important to point out that it has to be the full 15-minute increment because this differs from the typical CPT conventions for time-based billing. So I do have the code descriptor on the slide for you that does say that it's a prolonged office or other outpatient E&M visit beyond the maximum time required of the primary procedure, which has been selected using total time on the date of primary service, each 15 additional minutes by the physician or qualified healthcare professional with or without direct patient contact. So this is the Medicare code descriptor. The descriptor for 99417 differs slightly, but this code descriptor captures what Medicare is trying to convey, that it's when you're billing by time and it's each additional 15 minutes above that upper level threshold for a level 5. So this is something that is available to you now and has been since January 1st if you're billing by time. And it is worth an additional approximately $33. So if you're billing by time and you're spending that additional time, you should make sure that you take advantage of it. So let's look at the valuations of the new E&M codes. And so now I'm going to talk a little bit more about the conversion factor that I've mentioned a couple times. So before Congress stepped in, you will see here by the little pie chart, this is supposed to represent all of the services on the Medicare physician fee schedule. Outpatient E&M makes up 20% of fee schedule services. And so this is important because the fee schedule is budget neutral, meaning that basically Congress does not typically step in and put new money into the fee schedule. So if it's a budget neutral system and there are changes to the values of the codes, then that means that the values of other codes are going to change as well. And so there are two ways to do that. You can either lower the RV use of other services on the fee schedule, or you can make changes to the conversion factor. So when CMS was ultimately implementing the outpatient E&M policy, they decided not to lower the RV use of other services. What they did was they decreased the conversion factor. And what CMS had ultimately finalized before Congress stepped in was an over 10% cut to the conversion factor. So that eroded the values of the increases to the outpatient E&M codes, but it also significantly cut other fee schedule services. And for those of you who have a mix of procedures and E&M in your work, you would have really felt that impact in your procedural work as opposed to your E&M work. And so Congress stepped in, particularly because we're in the middle of a pandemic, and they did two things. They added another $3 billion to the physician fee schedule for one year. So that helped raise the conversion factor by about 3.75%. And then they issued that moratorium on G2211. And so any of the redistribution that was going to take effect because of the addition of that code has been put on hold. So ultimately, what we see here is the conversion factor still ended up falling because of the E&M policy, but it fell less than $2 to $34 and approximately 90 cents. That's the new conversion factor that's been in effect since January 1st, as opposed to what CMS had originally finalized was a conversion factor of $32 and change. So this again is a significant difference, and we're going to see ultimately what it means for the value of E&M services. But most importantly, I think what it means is the value of some of those procedural services that you might provide. You'll see that their values have stayed more stable than they would have otherwise. So these are a quick look at the work RVU values of the revised code family. And you will note that almost all of the outpatient E&M codes saw an increase in their RVUs, and this is because of the RUC survey that they went through. But I think more importantly, this is a look at what this ultimately means for payment. And I think this is important. Before Congress stepped in, actually all of the new patient codes 99202 through 99205 actually decreased in value. Now you see that they all are increasing, and that's because of the change in the conversion factor. And you'll even see if you look on both the outpatient and the facility side, particularly for the established patients, you see some pretty significant increases for these services. And then again, you'll note that if you're billing by time and you're seeing a level five patient or it's a level five visit, then that additional add-on code is available. And again, that is worth approximately $33, depending on whether you're seeing the patient as an outpatient or in a facility. So this is significant. And again, you can see the actual dollar values on this slide as well. So let's spend a little time thinking about documentation, since this is really where CMS made some major changes with the help of the CPT panel. And ultimately, again, CMS was looking to reduce the burden of the 1995-97 guidelines. That was their kind of driving force behind the original E&M policy. And ultimately, I think that burden reduction was accomplished by the changes that were made. So here's just a quick comparison of what the documentation under the 1995-97 guidelines looked like compared to the current guidelines. And so I think it's really important to note that history and physical exam are no longer part of the level selection for an outpatient E&M visit. Now they just need to be done in terms of what would be medically appropriate for the patient. So really you're just thinking about good patient care, not trying to document to, you know, reach a higher level or satisfy, you know, requirements of a certain visit level. And so in terms of level selection, again, you can now bill by time or medical decision making. And so those requirements have changed, and we'll look at them again in a little bit more detail. But again, time, I think it's really important to note that with this set of codes, now when you're billing by time, it's the total time on that day, the day of the visit, the pre-time, the visit time, and the post-time. So any time that you spend, again, in preparation or documenting after or, you know, calling in prescriptions or reviewing tests, that all counts when you're billing by time. Previously, the requirement for time was when you were, it would be more than 50% of the time spent face-to-face in counseling or coordination of care, and that does not apply anymore. The medical decision-making requirements have been updated. Some have said that they are still pretty complicated, but are vastly simplified from what you had to deal with before. And again, that add-on code is new. So documenting by time here, again, it's, I know I've said it all, said it multiple times, but it's all the time that you spend on the day of encounter. It's face-to-face and non-face-to-face, and it is the calendar day. So for instance, if you were to see a patient at 5 o'clock in the afternoon or 4.30 in the afternoon, if you spent time on that day, like early in the morning at like 6, preparing for the visit, reviewing test results, that time counts if you're going to bill by time. However, if you are charting late at night, like at 1.30 in the morning, that is now the new calendar day, so that time does not count. But again, if you were to be charting at 11.30 pm on that day, that time would count. So you want to count all the time that's unique to the visit on the calendar day. I have heard others say that they think that more documentation is going to be done by medical decision-making than by time, but I have heard that time may be used to reach a higher visit level for what may be a straightforward visit, but a time-consuming one. So just something to keep in mind that you might be able to reach just a higher level visit just because you spend a significant amount of time. And I, again, add-on code G2212 is available to you for, is available to you if you are spending more than 15 minutes above the upper level threshold for a level 5. And again, you see all of the time intervals for the codes on this, on this slide. So let's think a little bit about medical decision-making, particularly since the thought is that this is going to be the way that most E&M, outpatient E&M is documented. So it's the same basic, basic structure for medical decision-making. You're still looking at diagnoses and data and there's a table of risk, but there are new definitions that are much clearer and you're, you're not adding up tasks anymore. You're not really checking the box, but you're, you're looking at how the patient complexity and management component of medical decision-making is, is applied in that visit. So in order to select a level of E&M service, you have to meet the requirements for two of the following three elements for the visit level. And so that is the number and complexity of problems addressed, the amount and or complexity of data to be reviewed and analyzed, and their risk of complications under morbidity or mortality of the patient management. The AMA has a help, helpful chart that can be found online. I've linked to it here. Here is kind of a look at it. I know this slide is hard to read. So let, let's look at this a little bit more closely, but let's kind of focus in on a 99204, 99214 and the amount or complexity of data to be reviewed and analyzed. So here you'll see that you have to, they have a number of categories here for test documents or independent historians and then independent interpretation of tests and then discussion of management or test interpretation. You'll see, you have to meet the requirements of at least one out of the three categories. So you can figure out whichever one of them applies to the visit that you are completing, but let's kind of look at tests. It says you need any combination of three from the following for the tests. So if you have three, if you review the results of three unique tests, that would actually satisfy this. You don't need one from each category. You could have three of the same or you could have one prior external note, and then you could have two unique tests and that would actually satisfy the requirement for a moderate visit. So I think there are a lot of options here as you're looking at documentation and to reach different visit levels. It probably behooves you to spend some time familiarizing yourself with this table if you haven't already. And again, the link was on the slide before. So again, here's just kind of an overview of the revised codes and visit levels. You will see that it still goes from kind of a supervisory level with a 99211, and it goes from straightforward to high medical decision making. And again, I've put the times here for each visit level again, so you can see what they look like. And again, just as a reminder to bill the G2212 for Medicare patients for a new patient, you have to spend a minimum of 89 minutes with the patient. If you then for a new patient and 69 minutes for an established patient, it's then if you have an additional 15 minutes above those, then you can actually bill that add-on code twice or however many times you have exceeded that 15-minute interval. So keep that in mind because that is a way to, you know, potentially bill more. It's available to you and NCMS wants you to use it. So just very quickly, a comparison between what E&M last year versus E&M this year looks like. So on the left here, you will see you've got a 67-year-old established patient with viral hepatitis. You see them in your office and you go through, you decide to bill by medical decision making. You go through that chart and you meet the criteria for a level four. The only thing that has changed this year is the 99214 is now worth, you will see that it's, the code is now worth $122.94 as opposed to $110.43. So you, that's the difference. It's not $132.94, it's $122.94. And the difference is just based on the value of a 99214. On the other, in the other box, you'll see that a patient, this is a situation where you're billing by time. A 74-year-old new patient presents with NAFLD. The physician spends 94 minutes of time on the date of service, preparing for the visit, face-to-face with the patient and documenting the visit. So here you'll see not only has the value of a 99205 increased, but you can bill the add-on code G2212, which you're billing by time once because you have spent 74 minutes is the upper level of the 99205 time interval. And so again, that's 89 minutes to bill it once. So you can bill it once, you don't have enough to bill it twice. So you get to add that $33.85 to the new level five visit total. So again, you'll see that this visit is now worth $261 versus $211 approximately. So I think it really pays for you all to understand the new documentation requirements, figure out when it's appropriate to bill by time, because again, that's potentially another $33 that's available for those level five patients. But just the values of the codes themselves have increased in 2021. So you will see significant increases, whether you bill by medical decision making or time just based on those increases in the value of the codes. And then again, you know, if you're billing by time, there is that add-on code that's available to you. And so just to keep that in mind, that concludes my remarks. And so if you have any questions, please feel free to reach out to me by email. I've included my email address on the slides. So that's all and thank you very much for your attention.

evaluation and management codes

Centers for Medicare and Medicaid Services

E&M code policy

outpatient E&M code family

revised documentation requirements

billing scenarios