A simpler approach helps physicians properly report E/M services

Andis Robeznieks , Senior News Writer

Additions and revisions to the evaluation and management (E/M) portion of the Current Procedural Terminology (CPT®) code set help reduce physician administrative burdens, promote team-based care and can help shape policy.

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“The goal here is really to provide administrative simplification,” said Peter Hollmann, MD, a former chair of the CPT Editorial Panel and now vice chair of the AMA/Specialty Society RVS Update Committee (RUC).

Peter Hollmann, MD

“Another goal was also to make sure that we could continue to promote team-based care,” said Dr. Hollmann, a geriatrician and chief medical officer of the Brown Medicine faculty medical group, who spoke during the AMA CPT® and RBRVS Annual Symposium, held virtually this year.

The CPT refinements for reporting split and shared visits and AMA advocacy influenced Centers for Medicare & Medicaid Services (CMS) policy.

Dr. Hollmann said that the CPT Editorial Panel was hoping to guide CMS policy on this issue for 2025, and that it was a “nice surprise” that the final version of the 2024 physician payment schedule reflected CPT coding and was substantially revised from what CMS originally proposed.

Dr. Hollmann highlighted a statement from the CMS payment schedule fact sheet that discussed this.

“We are finalizing a revision to our definition of ‘substantive portion’ of a split (or shared) visit to include the revisions to the CPT guidelines, such that for Medicare billing purposes, the ‘substantive portion’ means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision-making,” the CMS statement says. “This responds to public comments asking that we allow either time or medical decision-making to serve as the substantive portion of a split (or shared) visit.”

In March, the AMA communicated with CMS on the issue. Read more (PDF).

When coding for E/M services, the CPT code set allows for physicians to choose between total time spent on the day of a patient encounter (including time spent in nonface-to-face activities) or the level of medical decision-making (MDM) involved.

When using CPT codes for time spent, the professional who spends the majority of the total time on the date of the encounter reports the service, said Dr. Hollmann.

But, when MDM is used to report the level of service, Dr. Hollmann said the CPT guidelines reflect the concept that who spends the most time with the patient is not as important as who’s responsible for bottom-line care decisions, he explained.

Specifically, the CPT 2024 Professional Edition codebook notes that “physicians and other qualified health care professionals (QHPs) may act as a team in providing care for the patient, working together during a single E/M service.”

“For the purpose of reporting E/M services within the context of team-based care, performance of a substantive part of the MDM requires that the physicians or other QHPs who made or approved the management plan for the number and complexity of problems addressed at the encounter take responsibility for that plan with its inherent risk of complications and/or morbidity or mortality,” the codebook adds.

Regarding coding for time, the CPT Editorial Panel replaced ranges of time with a time threshold for codes 99202–99205 and 99212–99215.

For example, with code 99205, used to report office-based or outpatient E/M services, the 60- to 74-minute time range was replaced with a threshold of 60 minutes that “must be met or exceeded” on the date of the encounter.

This was done to align with other more recent codes that use thresholds rather than ranges.

“That matches all the other E/M service guidelines.” Dr. Hollmann explained. “We didn’t want people to think that there’s something different about it.”

The CPT 2024 Professional Edition and CPT Changes 2024: An Insider’s View are available from the AMA Storefront on Amazon.