Braden Kuo, MD

Evaluation and Management (E/M) coding and guidelines are about to undergo the most significant changes since their implementation in the 1990s. For now, the changes are limited to new and established outpatient visits (CPT codes 99202-99205, 99211-99215) and will take place as of Jan. 1, 2021. Changes to all E/M codes are anticipated in the coming years.

The changes to the new and established office/outpatient codes will impact everyone in health care who assigns codes, manages health information, or pays claims including physicians and qualified health professionals, coders, health information managers, payers, health systems, and hospitals. The American Medical Association (AMA) has already released a preview of the CPT 2021 changes as well as free E/M education modules. They are planning to release more educational resources in the near future.
 

Why were changes needed?

The AMA developed the 2021 E/M changes in response to interest from the Centers for Medicare & Medicaid Services (CMS) in reducing physician burden, simplifying documentation requirements, and making changes to payments for the E/M codes. CMS’s initial proposal was to collapse office visit E/M levels 2-5 to a single payment. While the new rates would have provided a modest increase for level 2 and 3 E/M codes, they would have cut reimbursement for the top-level codes by more than 50%. There was concern that these changes would adversely affect physicians caring for complex patients across medical specialties. There was an outcry from the physician community opposing CMS’s proposal, and the agency agreed to get more input from the public before moving forward.

The AMA worked with stakeholders, including the AGA and our sister GI societies, to create E/M guidelines that decrease documentation requirements while also continuing to differentiate payment based on complexity of care. CMS announced in the 2020 Medicare Physician Fee Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommended relative values for 2021 CPT E/M codes. Of note, there will be modest payment increases for most office E/M codes beginning Jan. 1, 2021, which may benefit those who manage patients with complex conditions.

In sum, what are the 2021 E/M changes

While there will be many changes to office/outpatient E/M visits, the most significant are deletion of code 99201 (Level 1 new patient visit), addition of a 15-minute prolonged services code that can be reported with 99205 and 99215, and the following restructuring of office visit code selection:

1. Elimination of history and physical as elements for code selection: While obtaining a pertinent history and performing a relevant physical exam are clinically necessary and contribute to both time and medical decision making, these elements will not factor in to code selection. Instead, the code level will be determined solely by medical decision making or time.

2. Choice of using medical decision making (MDM) or total time as the basis of E/M level documentation:

• MDM. While there will still be three MDM subcomponents (number/complexity of problems, data, and risk), extensive edits were made to the ways in which these elements are defined and tallied.
• Time. The definition of time is now minimum time, not typical time or “face-to-face” time. Minimum time represents total physician/qualified health care professional time on the date of service. This redefinition of time allows Medicare to better recognize the work involved in non–face-to-face services like care coordination and record review. Of note, these definitions only apply when code selection is based on time and not MDM.

3. Modification of the criteria for MDM: The current CMS Table of Risk was used as a foundation for designing the revised required elements for MDM.

• Terms. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
• Definitions. Defined important terms, such as “independent historian.”
• Data elements. Re-defined the data elements to move away from simply adding up tasks to focusing on how those tasks affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with another physician).

CMS also plans to add a new Healthcare Common Procedure Coding System (HCPCS) add-on code as of Jan. 1, 2021, that can be used to recognize additional resource costs that are inherent in treating complex patients.

• GPCX1 - Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.).

GPC1X can be reported with all levels of E/M office/outpatient codes in which care of a patient’s single, serious, or complex chronic condition is the focus. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).
 

Who do these changes apply to?

The changes to the E/M office/outpatient CPT codes and guidelines for new and established patients apply to all traditional Medicare and Medicare Advantage plans, Medicaid, and all commercial payers. E/M HCPCS codes apply to Medicare, Medicare Advantage plans, and Medicaid only; commercial payers are not required to accept HCPCS codes.

What should you do?

Visit the AMA E/M Microsite; there you will find the AMA’s early release of the 2021 E/M coding and guideline changes, the AMA E/M learning module and future resources on the use of time and MDM that are expected to be released in March.

AMA E/M Microsite: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

2021 E/M changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

AMA E/M learning module: https://edhub.ama-assn.org/interactive/18057429

AMA MDM table: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Connect with your coders and/or medical billing company to create a plan for training physicians and staff to ensure a smooth transition on Jan. 1, 2021.

Contact your Electronic Health Records (EHR) vendor to confirm the system your practice uses will be ready to implement the new E/M coding and guidelines changes on Jan. 1, 2021.

Run an analysis using the new E/M office/outpatient payment rates recommended by the AMA for 2021 (https://www.ama-assn.org/about/rvs-update-committee-ruc/ruc-recommendations-minutes-voting) for each of your practice’s contracted payers to determine if your practice will benefit from the new rates. While CMS has proposed to accept the AMA recommended rates, this will not be finalized until CMS publishes the 2021 proposed rule in early July 2020.

Once CMS confirms its decision, reach out to your payers to negotiate implementing the new E/M rates starting in 2021.

With changes this big, we encourage you to prepare early. Watch for more information on the 2021 E/M changes in Washington Insider and AGA eDigest.
 

Dr. Kuo is the AGA’s Advisor to the AMA CPT Editorial Panel and a member of the AGA Practice Management and Economics Committee’s (PMEC) Coverage and Reimbursement Subcommittee (CRS) and assistant professor of medicine and gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston; Dr. Losurdo is the AGA’s Alternate Advisor to the AMA CPT Editorial Panel, a member of the AGA PMEC’s CRS, and Managing Partner and medical director of Illinois Gastroenterology Group, Elgin, Ill.; Dr. Mehta is the AGA’s advisor to the AMA RVS Update Committee (RUC), a member of the AGA PMEC’s CRS, and assistant professor of medicine at the University of Pennsylvania, Philadelphia; and Dr. Garcia is the AGA’s Alternate Advisor to the AMA RUC, a member of the AGA PMEC’s CRS, and assistant professor of medicine and gastroenterology at Stanford (Calif.) University. There were no conflicts of interest.

Evaluation and Management (E/M) coding and guidelines are about to undergo the most significant changes since their implementation in the 1990s. For now, the changes are limited to new and established outpatient visits (CPT codes 99202-99205, 99211-99215) and will take place as of Jan. 1, 2021. Changes to all E/M codes are anticipated in the coming years.

The changes to the new and established office/outpatient codes will impact everyone in health care who assigns codes, manages health information, or pays claims including physicians and qualified health professionals, coders, health information managers, payers, health systems, and hospitals. The American Medical Association (AMA) has already released a preview of the CPT 2021 changes as well as free E/M education modules. They are planning to release more educational resources in the near future.
 

Why were changes needed?

The AMA developed the 2021 E/M changes in response to interest from the Centers for Medicare & Medicaid Services (CMS) in reducing physician burden, simplifying documentation requirements, and making changes to payments for the E/M codes. CMS’s initial proposal was to collapse office visit E/M levels 2-5 to a single payment. While the new rates would have provided a modest increase for level 2 and 3 E/M codes, they would have cut reimbursement for the top-level codes by more than 50%. There was concern that these changes would adversely affect physicians caring for complex patients across medical specialties. There was an outcry from the physician community opposing CMS’s proposal, and the agency agreed to get more input from the public before moving forward.

The AMA worked with stakeholders, including the AGA and our sister GI societies, to create E/M guidelines that decrease documentation requirements while also continuing to differentiate payment based on complexity of care. CMS announced in the 2020 Medicare Physician Fee Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommended relative values for 2021 CPT E/M codes. Of note, there will be modest payment increases for most office E/M codes beginning Jan. 1, 2021, which may benefit those who manage patients with complex conditions.

In sum, what are the 2021 E/M changes

While there will be many changes to office/outpatient E/M visits, the most significant are deletion of code 99201 (Level 1 new patient visit), addition of a 15-minute prolonged services code that can be reported with 99205 and 99215, and the following restructuring of office visit code selection:

1. Elimination of history and physical as elements for code selection: While obtaining a pertinent history and performing a relevant physical exam are clinically necessary and contribute to both time and medical decision making, these elements will not factor in to code selection. Instead, the code level will be determined solely by medical decision making or time.

2. Choice of using medical decision making (MDM) or total time as the basis of E/M level documentation:

• MDM. While there will still be three MDM subcomponents (number/complexity of problems, data, and risk), extensive edits were made to the ways in which these elements are defined and tallied.
• Time. The definition of time is now minimum time, not typical time or “face-to-face” time. Minimum time represents total physician/qualified health care professional time on the date of service. This redefinition of time allows Medicare to better recognize the work involved in non–face-to-face services like care coordination and record review. Of note, these definitions only apply when code selection is based on time and not MDM.

3. Modification of the criteria for MDM: The current CMS Table of Risk was used as a foundation for designing the revised required elements for MDM.

• Terms. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
• Definitions. Defined important terms, such as “independent historian.”
• Data elements. Re-defined the data elements to move away from simply adding up tasks to focusing on how those tasks affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with another physician).

CMS also plans to add a new Healthcare Common Procedure Coding System (HCPCS) add-on code as of Jan. 1, 2021, that can be used to recognize additional resource costs that are inherent in treating complex patients.

• GPCX1 - Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.).

GPC1X can be reported with all levels of E/M office/outpatient codes in which care of a patient’s single, serious, or complex chronic condition is the focus. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).
 

Who do these changes apply to?

The changes to the E/M office/outpatient CPT codes and guidelines for new and established patients apply to all traditional Medicare and Medicare Advantage plans, Medicaid, and all commercial payers. E/M HCPCS codes apply to Medicare, Medicare Advantage plans, and Medicaid only; commercial payers are not required to accept HCPCS codes.

What should you do?

Visit the AMA E/M Microsite; there you will find the AMA’s early release of the 2021 E/M coding and guideline changes, the AMA E/M learning module and future resources on the use of time and MDM that are expected to be released in March.

AMA E/M Microsite: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

2021 E/M changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

AMA E/M learning module: https://edhub.ama-assn.org/interactive/18057429

AMA MDM table: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Connect with your coders and/or medical billing company to create a plan for training physicians and staff to ensure a smooth transition on Jan. 1, 2021.

Contact your Electronic Health Records (EHR) vendor to confirm the system your practice uses will be ready to implement the new E/M coding and guidelines changes on Jan. 1, 2021.

Run an analysis using the new E/M office/outpatient payment rates recommended by the AMA for 2021 (https://www.ama-assn.org/about/rvs-update-committee-ruc/ruc-recommendations-minutes-voting) for each of your practice’s contracted payers to determine if your practice will benefit from the new rates. While CMS has proposed to accept the AMA recommended rates, this will not be finalized until CMS publishes the 2021 proposed rule in early July 2020.

Once CMS confirms its decision, reach out to your payers to negotiate implementing the new E/M rates starting in 2021.

With changes this big, we encourage you to prepare early. Watch for more information on the 2021 E/M changes in Washington Insider and AGA eDigest.
 

Dr. Kuo is the AGA’s Advisor to the AMA CPT Editorial Panel and a member of the AGA Practice Management and Economics Committee’s (PMEC) Coverage and Reimbursement Subcommittee (CRS) and assistant professor of medicine and gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston; Dr. Losurdo is the AGA’s Alternate Advisor to the AMA CPT Editorial Panel, a member of the AGA PMEC’s CRS, and Managing Partner and medical director of Illinois Gastroenterology Group, Elgin, Ill.; Dr. Mehta is the AGA’s advisor to the AMA RVS Update Committee (RUC), a member of the AGA PMEC’s CRS, and assistant professor of medicine at the University of Pennsylvania, Philadelphia; and Dr. Garcia is the AGA’s Alternate Advisor to the AMA RUC, a member of the AGA PMEC’s CRS, and assistant professor of medicine and gastroenterology at Stanford (Calif.) University. There were no conflicts of interest.

Evaluation and Management (E/M) coding and guidelines are about to undergo the most significant changes since their implementation in the 1990s. For now, the changes are limited to new and established outpatient visits (CPT codes 99202-99205, 99211-99215) and will take place as of Jan. 1, 2021. Changes to all E/M codes are anticipated in the coming years.

The changes to the new and established office/outpatient codes will impact everyone in health care who assigns codes, manages health information, or pays claims including physicians and qualified health professionals, coders, health information managers, payers, health systems, and hospitals. The American Medical Association (AMA) has already released a preview of the CPT 2021 changes as well as free E/M education modules. They are planning to release more educational resources in the near future.
 

Why were changes needed?

The AMA developed the 2021 E/M changes in response to interest from the Centers for Medicare & Medicaid Services (CMS) in reducing physician burden, simplifying documentation requirements, and making changes to payments for the E/M codes. CMS’s initial proposal was to collapse office visit E/M levels 2-5 to a single payment. While the new rates would have provided a modest increase for level 2 and 3 E/M codes, they would have cut reimbursement for the top-level codes by more than 50%. There was concern that these changes would adversely affect physicians caring for complex patients across medical specialties. There was an outcry from the physician community opposing CMS’s proposal, and the agency agreed to get more input from the public before moving forward.

The AMA worked with stakeholders, including the AGA and our sister GI societies, to create E/M guidelines that decrease documentation requirements while also continuing to differentiate payment based on complexity of care. CMS announced in the 2020 Medicare Physician Fee Schedule (MPFS) final rule that it would adopt the AMA’s proposal as well as their recommended relative values for 2021 CPT E/M codes. Of note, there will be modest payment increases for most office E/M codes beginning Jan. 1, 2021, which may benefit those who manage patients with complex conditions.

In sum, what are the 2021 E/M changes

While there will be many changes to office/outpatient E/M visits, the most significant are deletion of code 99201 (Level 1 new patient visit), addition of a 15-minute prolonged services code that can be reported with 99205 and 99215, and the following restructuring of office visit code selection:

1. Elimination of history and physical as elements for code selection: While obtaining a pertinent history and performing a relevant physical exam are clinically necessary and contribute to both time and medical decision making, these elements will not factor in to code selection. Instead, the code level will be determined solely by medical decision making or time.

2. Choice of using medical decision making (MDM) or total time as the basis of E/M level documentation:

• MDM. While there will still be three MDM subcomponents (number/complexity of problems, data, and risk), extensive edits were made to the ways in which these elements are defined and tallied.
• Time. The definition of time is now minimum time, not typical time or “face-to-face” time. Minimum time represents total physician/qualified health care professional time on the date of service. This redefinition of time allows Medicare to better recognize the work involved in non–face-to-face services like care coordination and record review. Of note, these definitions only apply when code selection is based on time and not MDM.

3. Modification of the criteria for MDM: The current CMS Table of Risk was used as a foundation for designing the revised required elements for MDM.

• Terms. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
• Definitions. Defined important terms, such as “independent historian.”
• Data elements. Re-defined the data elements to move away from simply adding up tasks to focusing on how those tasks affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with another physician).

CMS also plans to add a new Healthcare Common Procedure Coding System (HCPCS) add-on code as of Jan. 1, 2021, that can be used to recognize additional resource costs that are inherent in treating complex patients.

• GPCX1 - Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.).

GPC1X can be reported with all levels of E/M office/outpatient codes in which care of a patient’s single, serious, or complex chronic condition is the focus. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).
 

Who do these changes apply to?

The changes to the E/M office/outpatient CPT codes and guidelines for new and established patients apply to all traditional Medicare and Medicare Advantage plans, Medicaid, and all commercial payers. E/M HCPCS codes apply to Medicare, Medicare Advantage plans, and Medicaid only; commercial payers are not required to accept HCPCS codes.

What should you do?

Visit the AMA E/M Microsite; there you will find the AMA’s early release of the 2021 E/M coding and guideline changes, the AMA E/M learning module and future resources on the use of time and MDM that are expected to be released in March.

AMA E/M Microsite: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

2021 E/M changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

AMA E/M learning module: https://edhub.ama-assn.org/interactive/18057429

AMA MDM table: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Connect with your coders and/or medical billing company to create a plan for training physicians and staff to ensure a smooth transition on Jan. 1, 2021.

Contact your Electronic Health Records (EHR) vendor to confirm the system your practice uses will be ready to implement the new E/M coding and guidelines changes on Jan. 1, 2021.

Run an analysis using the new E/M office/outpatient payment rates recommended by the AMA for 2021 (https://www.ama-assn.org/about/rvs-update-committee-ruc/ruc-recommendations-minutes-voting) for each of your practice’s contracted payers to determine if your practice will benefit from the new rates. While CMS has proposed to accept the AMA recommended rates, this will not be finalized until CMS publishes the 2021 proposed rule in early July 2020.

Once CMS confirms its decision, reach out to your payers to negotiate implementing the new E/M rates starting in 2021.

With changes this big, we encourage you to prepare early. Watch for more information on the 2021 E/M changes in Washington Insider and AGA eDigest.
 

Dr. Kuo is the AGA’s Advisor to the AMA CPT Editorial Panel and a member of the AGA Practice Management and Economics Committee’s (PMEC) Coverage and Reimbursement Subcommittee (CRS) and assistant professor of medicine and gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston; Dr. Losurdo is the AGA’s Alternate Advisor to the AMA CPT Editorial Panel, a member of the AGA PMEC’s CRS, and Managing Partner and medical director of Illinois Gastroenterology Group, Elgin, Ill.; Dr. Mehta is the AGA’s advisor to the AMA RVS Update Committee (RUC), a member of the AGA PMEC’s CRS, and assistant professor of medicine at the University of Pennsylvania, Philadelphia; and Dr. Garcia is the AGA’s Alternate Advisor to the AMA RUC, a member of the AGA PMEC’s CRS, and assistant professor of medicine and gastroenterology at Stanford (Calif.) University. There were no conflicts of interest.

Welcome to the new Practice Management Toolbox.

The AGA Practice Management and Economics Committee (PMEC) is pleased to host an updated Practice Management Toolbox column featuring contemporary GI practice management issues and news. As chair of the PMEC, I am excited to bring you this content on behalf of my colleagues on the committee. Each month we will highlight a timely topic relevant to gastroenterologists in practice. The AGA and PMEC strive to be at the forefront of changes to the field of gastroenterology, providing you with tools and resources to succeed. If there is an article topic you would like to suggest, please reach out to Jacob Manthey, Practice and Quality Manager at jmanthey@gastro.org .
 

Anton Decker, MD, AGAF
Chair, Practice Management and Economics Committee

Last year, Medicare began laying groundwork for major changes to coding and payment for common evaluation and management (E/M) services and two high-volume GI endoscopy procedures beginning January 1, 2021 with expected adoption by commercial payers. Learn about these potential changes now to help prepare your practice for the financial impact.

2021 E/M Changes: New guidelines, new payments

The Centers for Medicare and Medicaid Services (CMS), also commonly referred to as Medicare, announced in its 2019 Physician Fee Schedule proposed rule that it wanted to reduce administrative burden and improve payment accuracy for office/outpatient new and established patient codes (99201-99205 and 99211-99215) by paying level 2–5 codes at a single payment rate and simplifying documentation to support only a level 2 E/M visit, except when using time for documentation (Table).

In the original proposal, those who reported mostly level 2 and 3 E/M visits would have experienced modest payment increases while those who reported mostly level 4 and 5 E/M visits would have endured payment cuts between 20%-40%. Ultimately, the physician community, including AGA and its sister societies, opposed the proposed payment consolidation and pressured CMS not to finalize most of its proposed changes and preserve the current payment rates. The 2019 MPFS final rule made no changes to the relative values for office/outpatient new and established patient codes 99201-99205 and 99211-99215, but did outline a new plan “for paying a single rate for E/M office/outpatient visit levels 2 through 4 for established and new patients while maintaining the payment rate for E/M office/outpatient visit level 5 in order to better account for the care and needs of complex patients.” CMS agreed to continue to accept input on improvements to the proposal before CMS’ planned implementation in 2021.

A proposal to simplify E/M guidelines within Current Procedural Terminology (CPT) and preserve the individual levels of the new and established patient office/outpatient E/M codes, except 99201 which was proposed for deletion, was presented to the American Medical Association (AMA) CPT Editorial Panel, the body responsible for creating and maintaining CPT codes, and approved at its February 2019 meeting. The approved changes will not be publicly available until the CPT 2021 book is released in August 2020. In the meantime, the AMA Specialty Society Relative-value scale Update Committee (RUC) will make recommendations to CMS on potential new relative values for the E/M codes.

It is unclear whether CMS will accept the AMA CPT Editorial Panel’s changes and potential new values or move forward with the plan for three levels of E/M for office/outpatient new and established patient codes. However, any changes to the current guidelines will undoubtedly involve a learning curve for both physicians and coders and it is unclear whether approximately four months from the time the 2021 CPT book is released and the time the new rates will be implemented on January 1, 2021 is enough to master the changes and update internal systems. In addition, any changes to reimbursement will impact each practice’s bottom line.
 

2021 potential payment changes for CPT codes 43239 and 45385

In the same proposed rule, CMS announced that an unnamed party had nominated seven CPT codes, including esophagogastroduodenoscopy (EGD) with biopsy (CPT code 43239) and colonoscopy with snare polypectomy (CPT code 45385), as potentially overvalued and recommended reducing their reimbursement based on data from the 2017 Urban Institute report for CMS. The AGA and its sister societies pointed out to CMS major flaws in the Urban Institute study’s methods that should have prevented its use as evidence that the codes were misvalued and we provided data from the GI societies’ robust sample of physicians to support the current values.

In the 2019 MPFS final rule, CMS revealed Anthem, a major U.S. health insurance company, as the nominating party sparking concern that this unprecedented development may result in other payers using the flawed Urban Institute study to influence CMS to revalue other services.

Codes CMS identified as potentially misvalued in the 2019 MPFS final rule were referred to the RUC for resurvey of physician work and practice expense for consideration at the April 2019 RUC meeting. The AGA and its sister societies conducted a survey of a random sample of our memberships during February and March and presented our recommendations based on the data we collected. CMS’ proposed values will be published in July 2020 in the 2021 MPFS proposed rule and finalized in the final rule that November.
 

Next steps

CMS will announce changes to E/M coding and documentation guidelines and any new payment changes to CPT codes 43239 and 45385 in the 2021 MPFS proposed rule in July 2020. Be prepared to use this information to model the financial impact to your practice so you can determine what, if any changes, should be made. Contact your coding and billing staff, consultants and software providers to find out how they plan to implement any changes. Additional E/M training may be required for your providers and staff. The GI Societies remain vigilant and continue to advocate on the behalf of its members to advise and shape these policy evaluations and changes.
 

Dr. Kuo is assistant professor, director of the Center for Neurointestinal Health, GI Unit, Massachusetts General Hospital, Harvard Medical School, Boston; AGA CPT Advisor; he has no conflicts of interest. Dr. Mehta is assistant professor, Perelman School of Medicine; associate chief innovation officer, Penn Medicine, Philadelphia; AGA RUC Advisor; he has no conflicts of interest.

Welcome to the new Practice Management Toolbox.

The AGA Practice Management and Economics Committee (PMEC) is pleased to host an updated Practice Management Toolbox column featuring contemporary GI practice management issues and news. As chair of the PMEC, I am excited to bring you this content on behalf of my colleagues on the committee. Each month we will highlight a timely topic relevant to gastroenterologists in practice. The AGA and PMEC strive to be at the forefront of changes to the field of gastroenterology, providing you with tools and resources to succeed. If there is an article topic you would like to suggest, please reach out to Jacob Manthey, Practice and Quality Manager at jmanthey@gastro.org .
 

Anton Decker, MD, AGAF
Chair, Practice Management and Economics Committee

Last year, Medicare began laying groundwork for major changes to coding and payment for common evaluation and management (E/M) services and two high-volume GI endoscopy procedures beginning January 1, 2021 with expected adoption by commercial payers. Learn about these potential changes now to help prepare your practice for the financial impact.

2021 E/M Changes: New guidelines, new payments

The Centers for Medicare and Medicaid Services (CMS), also commonly referred to as Medicare, announced in its 2019 Physician Fee Schedule proposed rule that it wanted to reduce administrative burden and improve payment accuracy for office/outpatient new and established patient codes (99201-99205 and 99211-99215) by paying level 2–5 codes at a single payment rate and simplifying documentation to support only a level 2 E/M visit, except when using time for documentation (Table).

In the original proposal, those who reported mostly level 2 and 3 E/M visits would have experienced modest payment increases while those who reported mostly level 4 and 5 E/M visits would have endured payment cuts between 20%-40%. Ultimately, the physician community, including AGA and its sister societies, opposed the proposed payment consolidation and pressured CMS not to finalize most of its proposed changes and preserve the current payment rates. The 2019 MPFS final rule made no changes to the relative values for office/outpatient new and established patient codes 99201-99205 and 99211-99215, but did outline a new plan “for paying a single rate for E/M office/outpatient visit levels 2 through 4 for established and new patients while maintaining the payment rate for E/M office/outpatient visit level 5 in order to better account for the care and needs of complex patients.” CMS agreed to continue to accept input on improvements to the proposal before CMS’ planned implementation in 2021.

A proposal to simplify E/M guidelines within Current Procedural Terminology (CPT) and preserve the individual levels of the new and established patient office/outpatient E/M codes, except 99201 which was proposed for deletion, was presented to the American Medical Association (AMA) CPT Editorial Panel, the body responsible for creating and maintaining CPT codes, and approved at its February 2019 meeting. The approved changes will not be publicly available until the CPT 2021 book is released in August 2020. In the meantime, the AMA Specialty Society Relative-value scale Update Committee (RUC) will make recommendations to CMS on potential new relative values for the E/M codes.

It is unclear whether CMS will accept the AMA CPT Editorial Panel’s changes and potential new values or move forward with the plan for three levels of E/M for office/outpatient new and established patient codes. However, any changes to the current guidelines will undoubtedly involve a learning curve for both physicians and coders and it is unclear whether approximately four months from the time the 2021 CPT book is released and the time the new rates will be implemented on January 1, 2021 is enough to master the changes and update internal systems. In addition, any changes to reimbursement will impact each practice’s bottom line.
 

2021 potential payment changes for CPT codes 43239 and 45385

In the same proposed rule, CMS announced that an unnamed party had nominated seven CPT codes, including esophagogastroduodenoscopy (EGD) with biopsy (CPT code 43239) and colonoscopy with snare polypectomy (CPT code 45385), as potentially overvalued and recommended reducing their reimbursement based on data from the 2017 Urban Institute report for CMS. The AGA and its sister societies pointed out to CMS major flaws in the Urban Institute study’s methods that should have prevented its use as evidence that the codes were misvalued and we provided data from the GI societies’ robust sample of physicians to support the current values.

In the 2019 MPFS final rule, CMS revealed Anthem, a major U.S. health insurance company, as the nominating party sparking concern that this unprecedented development may result in other payers using the flawed Urban Institute study to influence CMS to revalue other services.

Codes CMS identified as potentially misvalued in the 2019 MPFS final rule were referred to the RUC for resurvey of physician work and practice expense for consideration at the April 2019 RUC meeting. The AGA and its sister societies conducted a survey of a random sample of our memberships during February and March and presented our recommendations based on the data we collected. CMS’ proposed values will be published in July 2020 in the 2021 MPFS proposed rule and finalized in the final rule that November.
 

Next steps

CMS will announce changes to E/M coding and documentation guidelines and any new payment changes to CPT codes 43239 and 45385 in the 2021 MPFS proposed rule in July 2020. Be prepared to use this information to model the financial impact to your practice so you can determine what, if any changes, should be made. Contact your coding and billing staff, consultants and software providers to find out how they plan to implement any changes. Additional E/M training may be required for your providers and staff. The GI Societies remain vigilant and continue to advocate on the behalf of its members to advise and shape these policy evaluations and changes.
 

Dr. Kuo is assistant professor, director of the Center for Neurointestinal Health, GI Unit, Massachusetts General Hospital, Harvard Medical School, Boston; AGA CPT Advisor; he has no conflicts of interest. Dr. Mehta is assistant professor, Perelman School of Medicine; associate chief innovation officer, Penn Medicine, Philadelphia; AGA RUC Advisor; he has no conflicts of interest.

Welcome to the new Practice Management Toolbox.

The AGA Practice Management and Economics Committee (PMEC) is pleased to host an updated Practice Management Toolbox column featuring contemporary GI practice management issues and news. As chair of the PMEC, I am excited to bring you this content on behalf of my colleagues on the committee. Each month we will highlight a timely topic relevant to gastroenterologists in practice. The AGA and PMEC strive to be at the forefront of changes to the field of gastroenterology, providing you with tools and resources to succeed. If there is an article topic you would like to suggest, please reach out to Jacob Manthey, Practice and Quality Manager at jmanthey@gastro.org .
 

Anton Decker, MD, AGAF
Chair, Practice Management and Economics Committee

Last year, Medicare began laying groundwork for major changes to coding and payment for common evaluation and management (E/M) services and two high-volume GI endoscopy procedures beginning January 1, 2021 with expected adoption by commercial payers. Learn about these potential changes now to help prepare your practice for the financial impact.

2021 E/M Changes: New guidelines, new payments

The Centers for Medicare and Medicaid Services (CMS), also commonly referred to as Medicare, announced in its 2019 Physician Fee Schedule proposed rule that it wanted to reduce administrative burden and improve payment accuracy for office/outpatient new and established patient codes (99201-99205 and 99211-99215) by paying level 2–5 codes at a single payment rate and simplifying documentation to support only a level 2 E/M visit, except when using time for documentation (Table).

In the original proposal, those who reported mostly level 2 and 3 E/M visits would have experienced modest payment increases while those who reported mostly level 4 and 5 E/M visits would have endured payment cuts between 20%-40%. Ultimately, the physician community, including AGA and its sister societies, opposed the proposed payment consolidation and pressured CMS not to finalize most of its proposed changes and preserve the current payment rates. The 2019 MPFS final rule made no changes to the relative values for office/outpatient new and established patient codes 99201-99205 and 99211-99215, but did outline a new plan “for paying a single rate for E/M office/outpatient visit levels 2 through 4 for established and new patients while maintaining the payment rate for E/M office/outpatient visit level 5 in order to better account for the care and needs of complex patients.” CMS agreed to continue to accept input on improvements to the proposal before CMS’ planned implementation in 2021.

A proposal to simplify E/M guidelines within Current Procedural Terminology (CPT) and preserve the individual levels of the new and established patient office/outpatient E/M codes, except 99201 which was proposed for deletion, was presented to the American Medical Association (AMA) CPT Editorial Panel, the body responsible for creating and maintaining CPT codes, and approved at its February 2019 meeting. The approved changes will not be publicly available until the CPT 2021 book is released in August 2020. In the meantime, the AMA Specialty Society Relative-value scale Update Committee (RUC) will make recommendations to CMS on potential new relative values for the E/M codes.

It is unclear whether CMS will accept the AMA CPT Editorial Panel’s changes and potential new values or move forward with the plan for three levels of E/M for office/outpatient new and established patient codes. However, any changes to the current guidelines will undoubtedly involve a learning curve for both physicians and coders and it is unclear whether approximately four months from the time the 2021 CPT book is released and the time the new rates will be implemented on January 1, 2021 is enough to master the changes and update internal systems. In addition, any changes to reimbursement will impact each practice’s bottom line.
 

2021 potential payment changes for CPT codes 43239 and 45385

In the same proposed rule, CMS announced that an unnamed party had nominated seven CPT codes, including esophagogastroduodenoscopy (EGD) with biopsy (CPT code 43239) and colonoscopy with snare polypectomy (CPT code 45385), as potentially overvalued and recommended reducing their reimbursement based on data from the 2017 Urban Institute report for CMS. The AGA and its sister societies pointed out to CMS major flaws in the Urban Institute study’s methods that should have prevented its use as evidence that the codes were misvalued and we provided data from the GI societies’ robust sample of physicians to support the current values.

In the 2019 MPFS final rule, CMS revealed Anthem, a major U.S. health insurance company, as the nominating party sparking concern that this unprecedented development may result in other payers using the flawed Urban Institute study to influence CMS to revalue other services.

Codes CMS identified as potentially misvalued in the 2019 MPFS final rule were referred to the RUC for resurvey of physician work and practice expense for consideration at the April 2019 RUC meeting. The AGA and its sister societies conducted a survey of a random sample of our memberships during February and March and presented our recommendations based on the data we collected. CMS’ proposed values will be published in July 2020 in the 2021 MPFS proposed rule and finalized in the final rule that November.
 

Next steps

CMS will announce changes to E/M coding and documentation guidelines and any new payment changes to CPT codes 43239 and 45385 in the 2021 MPFS proposed rule in July 2020. Be prepared to use this information to model the financial impact to your practice so you can determine what, if any changes, should be made. Contact your coding and billing staff, consultants and software providers to find out how they plan to implement any changes. Additional E/M training may be required for your providers and staff. The GI Societies remain vigilant and continue to advocate on the behalf of its members to advise and shape these policy evaluations and changes.
 

Dr. Kuo is assistant professor, director of the Center for Neurointestinal Health, GI Unit, Massachusetts General Hospital, Harvard Medical School, Boston; AGA CPT Advisor; he has no conflicts of interest. Dr. Mehta is assistant professor, Perelman School of Medicine; associate chief innovation officer, Penn Medicine, Philadelphia; AGA RUC Advisor; he has no conflicts of interest.