Many know the 1995 (or 1997) Documentation Guidelines as the gold standard reference when it comes to medical record documentation, especially as it relates to the evaluation and management services (i.e. E/M) and coding. It is hard to believe that the documents have stood the test of time given they are now over 20 years old. However, they define the medical record to consist of three components: the case history, the physical exam, and medical decision making. Ultimately, if the provider documents precisely what was performed during the course of the visit, then the elements addressed in each of the three areas helps determine the final coding for the visit.
At least that is the way it has worked. Beginning in 2021, the historical process for 99xxx series office visit code determination was thrown out the window. In its place began a new system that allows the provider to base the final code on one of two approaches:
- Consideration of the total time personally spent by the reporting practitioner on the day of the visit, OR
- Consideration of medical decision making (MDM).
That is it. No longer will you (or your EHR) need to count up the elements of the case history and physical exam to determine the final visit code. Ultimately, the AMA and CMS believe that the old approach is outdated, especially in the world of EHRs where much of that information could be easily reviewed rather than re-entered into today’s record. Importantly, nobody is saying that a case history or physical exam should not be performed, but simply that they should be documented as “medically appropriate.”
So that begs the question, “how do I use time or MDM to determine the code for the visit?” Let’s tackle each separately. First, regardless of the approach chosen, 99201 would be removed and no longer available to use. This leaves four codes for new patients and five for established patients.
If time is the selected approach, here is how one would determine the final visit code for a new patient:
If 75 minutes is exceeded, then a new code (99417) would be used to account for 15-minute blocks of time over 60 minutes. For example, an 80-minute encounter would be coded as 99205 + one unit of 99417. A 100-minute encounter would be coded 99205 + two units of 99417. In both examples, note that another unit of 99417 cannot be added until the next threshold has been reached. Said differently, 80 minutes is 20 more than 60. But rather than add two units of 99417 (one for the first 15 and then another for the next 5), only one is used. Only after the encounter lasted 90 minutes would I be able to add the second unit.
|99211||No doctor presence|
In the case of an established patient, if 54 minutes is exceeded, then code 99417 is used to account for 15-minute blocks of time over 40 minutes. Thus, a 54-minute encounter is coded as 99215 while a 55 minute encounter could be coded as 99215 + 99417.
As you can imagine, when coding based on time it is very important the total time spent is documented in the record. With that in mind, what can be included in that time estimate? Per the AMA, total time on the date of the encounter is defined as:
- both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).
Physician/other qualified health care professional time includes the following activities, when performed:
- preparing to see the patient (e.g., review of tests),
- obtaining and/or reviewing separately obtained history,
- performing a medically appropriate examination and/or evaluation,
- counseling and educating the patient/family/caregiver,
- ordering medications, tests, or procedures,
- referring and communicating with other health care professionals (when not separately reported),
- documenting clinical information in the electronic or other health record,
- independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver,
- care coordination (when not separately reported).
When MDM is instead utilized, each of the four levels of medical decision making have their own code and there is no differentiation between new and established patients. Note that the concept of MDM does not apply to 99211 since this level of service rarely involves a physician or other provider:
|99202 / 99212||Straightforward MDM|
|99203 / 99213||Low MDM|
|99204 / 99214||Moderate MDM|
|99205 / 99215||High MDM|
Change is rarely easy, especially when it pertains to a system that has been in place for over 20 years.
If you would like to dive deeper into the topic, including the revised descriptions of MDM levels, the AMA has a number of resources available here.