Patient Visit Codes Are Changing: Know What to Do to Get Paid

Betsy Nicoletti, MS

Disclosures

December 23, 2019

Editor's Note:

Betsy Nicoletti, MS, a nationally recognized coding expert, will take your coding questions via email and provide guidance on how to code properly to maximize reimbursement. Have a question about coding? Send it here.

In this column, Nicoletti discusses upcoming changes to coding patient visits as well as coding for initial and subsequent malignancies.

Changes Coming to Office Visit Codes

Question: At my family practice, my office manager and I have recently been debating over coding. She reports that the new coding system has changed our typical 99214 visits into 99213s.

For example, I see a patient for routine follow-up on three or more chronic conditions. All past labs are reviewed, meds are reconciled, relevant physical exam is done, and future labs are ordered. No med changes are made. The average time with patient is 15 minutes. Is this a 99213 or 99214?

My office manager says because no medication change was made, it's a 99213. If any med is changed, it then becomes a 99214. Who is correct?

Answer: Nothing is changing in evaluation and management coding in 2020. However, in 2021, Current Procedural Terminology (CPT) is deleting code 99201 and allowing physicians to select new and established patient visit codes (99202-99215) on the basis of a time range or medical decision-making (MDM).

Neither history nor exam will be a key component, but rather the nature and extent of those will be determined by the physician, nurse practitioner, or physician assistant. CPT has assigned time ranges to these codes, and will allow the clinician to include non–face-to-face, noncounseling time.

From the American Medical Association:

E/M Code Current Time (min) Time in 2021 (min)
99202 20 15-29
99203 30 30-44
99204 45 45-59
99205 60 60-74
99211 5 [a]
99212 10 10-19
99213 15 20-29
99214 25 30-39
99215 40 40-54

E/M = evaluation and management

As for MDM, there is no requirement that a medication would need to be changed in order to be counted as prescription drug management. As you describe the scenario, two or more stable chronic problems with prescription drug management would continue to be assigned moderate MDM, the level required for 99214.

Currently, code level may be selected on the basis of two of the three key components of history, exam, and MDM. If many of a physician's codes are selected by history and exam, and those are at a higher level than the MDM requirement for the level, you may see your coding levels decline. If a physician's documentation currently shows a higher-level MDM, but with briefer history and exam, code levels may rise.

Before 2021, CPT will release more detailed information. At this point, predictions about an individual physician's code levels may not be accurate.

The Centers for Medicare & Medicaid Services is endorsing this change and will follow the new CPT guidelines in 2021, rescinding their plan for a single payment for code levels 2 through 4.

Coding for Primary Versus Secondary Malignancy

Question: If a patient has endometrial cancer, undergoes hysterectomy for treatment, and then 5 years later has recurrence of endometrial cancer with metastases to colon, lungs, and lymph nodes, do I still code personal history of endometrial cancer along with the codes for secondary malignant neoplasm of colon, lung, and lymph nodes? Or should I use the code for endometrial cancer, even though she no longer has a uterus?

Answer: Use the code for the secondary malignancy, not the primary malignancy. You are correct not to use the primary code now, because the primary malignancy was removed. The secondary malignancy code for endometrial cancer is C79.82, secondary malignant neoplasm of genital organs.

You can add a secondary code from category Z85. Z85.42 is defined as "personal history of malignant neoplasm of other parts of the uterus."

Here is some additional guidance in coding neoplasms:

  • If the patient has evidence of the primary malignancy, use the primary malignancy code.

  • If the primary malignancy has been previously excised or eradicated from its site, and there is no further evidence of disease or treatment directed at that site, use personal history of malignant neoplasm.

  • If the patient is either receiving treatment or still has evidence of the primary malignancy, continue to use the primary malignancy code.

  • If the primary malignancy was excised or eradicated, but there is a secondary metastasis, use the secondary malignancy code.

These codes are found in the ICD-10 neoplasm table.

Have a coding question? Send it in and it may be answered in a future column. (Please be sure to note your specialty in the text of the question.)

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