Will commercial payers, EHR vendors adopt revised E/M office-visit codes?

Andis Robeznieks , Senior News Writer

Revised evaluation and management (E/M) office-visit codes that take effect Jan. 1 are designed to reduce the administrative burdens placed on physicians and other clinicians. Although CMS finalized in late 2019 its intent to adopt the revised codes, uncertainty persists about whether private insurance companies, electronic health record (EHR) vendors, and others in the health care ecosystem will adopt the revised codes. Namely, are these organizations required to adopt the most recent version of CPT codes for evaluation and management visits?

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The AMA has been working closely with these stakeholders, and a new AMA resource—entitled “ Are commercial health plans required to adopt the revisions to E/M codes?”—not only answers this question, , but also clarifies several other lingering issues.

The resource notes the following regarding the updated Current Procedural Terminology (CPT®) E/M codes:

  • The revisions only apply to outpatient and office visits.
  • Code 99201 has been eliminated.
  • Codes 99202–99215 descriptors and documentation standards have been simplified.

These revisions reflect that only a medically necessary history and/or exam must be documented and will no longer be used to directly determine the appropriate code selection.

The revisions allow clinicians to select the E/M visit level based on either medical decision-making (MDM) or the total time spent on the date of the encounter—including time spent conducting nonface-to-face activities.

The changes aim to reduce the need for audits by providing greater clarity and standardization to coding and billing based on MDM.

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The resource seeks to provide answers to these questions:

Yes. The CPT code set, together with the U.S. Department of Health and Human Services’ Healthcare Common Procedure Coding System, has been adopted as the nation’s standard medical data code set. HIPAA requires that health plans use the most recent version of the medical data code set, so they should be ready to implement the revisions Jan. 1.

No. Other clinicians, coders, third-party plan administrators, and other health care-related entities should start using the revised code set Jan. 1. Physician practices should confirm that their contracted health plans and EHR vendors are integrating the revised codes into their software systems and will be ready Jan. 1.

Yes. But it is important that physicians confirm with their EHR vendor that their system’s code-selection application conforms to the revised codes and descriptors because the billing provider has the ultimate responsibility for appropriate coding.

Learn how the AMA is providing guidance for physicians in their day-to-day practice environment.

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The AMA offers free tools and resources to keep physicians current on critical updates, including:

  • Step-by-step videos on using MDM criteria or total time to select a code.
  • A table illustrating the MDM revisions.
  • A 10-step checklist to prepare your practice.
  • A detailed document with the E/M code and guideline changes.
  • An interactive, educational module, “Office Evaluation and Management (E/M) CPT Code Revisions.”