Coding changes scheduled to take effect January 1, 2021 will have far-reaching effects on the orthopaedic specialty. History and exam components will no longer play a significant role in code selection, although they will still be medically appropriate for reporting all service levels. Instead, providers will select codes based on level of medical decision making (MDM) or total time spent. Read on to learn how changes will affect new and established outpatient visits.
Details and Coding Specifics
The changes affect Current Procedural Terminology (CPT) codes 99201-99205, as well as 99211-99215. CPT code 99201 will be omitted in 2021. Also, time as defined for codes 99202-99215 will be changed to “total time spent on the day of the encounter.” This change means that providers will no longer need to establish amount of time given to counseling and coordination, since values will reflect total time spent.
Additional changes have been made to billing for prolonged services. The 2020 Physician Fee Schedule Final Rule contains exclusion for reporting CPT codes 99358 and 99359 (Prolonged Services Without Direct Face-to-Face Patient Contact Services) when using total time as the deciding factor for an E/M service. Furthermore, revisions to MDM elements for 99202-99215 will including wording edits. These include:
- Number of Diagnoses or Management Options will change to Number and Complexity of Problems Addressed
- Amount and/or Complexity of Data to be Reviewed will change to Amount and/or Complexity of Data to be Reviewed and Analyzed
- Risk of Complications and/or Morbidity or Mortality will change to Risk of Complications and/or Morbidity or Mortality of Patient Management
Effects on Orthopaedic Practices
Documentation requirements have been reduced for providers by making MDM and total time the sole factors in code selection. The CPT code changes apply to all Medicare, Medicare Advantage and Medicaid plans along with commercial payers, although all commercial payers may not acknowledge them. Since only outpatient office visit codes are affected at this time, the heaviest impact will be on private practice and practices where providers see many Medicare patients.
These factors intersect in outpatient orthopaedics, making it critical to familiarize yourself with the changes and have a transition plan in place. The American Medical Association has released a checklist to assist practices in preparing for the changes prior to January 1st. You can find the checklist here.
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