Changes on the horizon for evaluation and management services

AOA's Coding Experts Doug Morrow, O.D., Harvey Richman, O.D., and Rebecca Wartman, O.D.

There has been a lot of information disseminated by various individuals and organizations regarding upcoming changes to coding and reimbursement for evaluation and management services (E/M services). Given the importance of E/M services in patient care, it's critical that all doctors of optometry are aware of these changes.

In 2018, the Centers for Medicare and Medicaid Services (CMS) proposed to ­reduce ­the payment variation for office/outpatient E/M visit levels by paying a single rate for office/outpatient E/M visit levels 2 through 4 (one rate for established patients and another rate for new patients), while maintaining the payment rate for office/outpatient E/M visit level 5. The AOA and other physician organizations spoke out against this proposal, and the AOA has been engaged in the effort over the past 12 months to ensure that billing and coding for these foundational services are equitable and appropriate. Here's what doctors of optometry need to know.

There are no changes for 2020

Continue to report existing CPT codes for new and established patient visits (99201-99215) and for prolonged face-to-face of­fice visit time (99354-99355).

Visit level selection remains based upon three key components (history, physical exam and medical decision making [MDM] complexity).

You can choose to use either the 1995 or 1997 E/M documentation guidelines.

Time may be used for level selection only when over 50% of the visit's face-to-face time consists of counseling and/or care coordination, in which case level selection is guided by the "typical times" that accompany the code descriptors.

In 2019, CMS updated its documentation requirements. For E/M of­fice/outpatient visits, for new and established patients, doctors do not need to re-enter in the medical record information on the patient's chief complaint and history that has already been entered by ancillary staff or the bene­ficiary. The doctor may simply indicate in the medical record that he or she reviewed and veri­fied this information. That policy remains for 2020.

Changes are coming in 2021

• CMS has proposed to adopt for 2021 the of­fice visit codes as revised by the CPT Editorial Panel.
• CPT 99201 will be deleted in 2021.
• You can choose the E/M visit level based on either medical decision-making or time.
• The revised code descriptors require history and physical exam performance only to the extent medically necessary and clinically appropriate; history and exam are no longer considered key components for level selection.
• Ranges for total time (face-to-face and non-face-to-face) expended by the billing clinician in caring for a patient on the date of the patient's of­fice visit are given for each code, replacing the typical face-to-face times previously provided.