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Coding Corner: Prepare for CPT® 2020 online E/M changes

November 08, 2019
Area(s) of Interest: Practice Management Payor Issues and Reimbursement 


CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from Deborah Marsh, senior content specialist for AAPC, a training and credentialing association for the business side of health care.

The American Medical Association (AMA) has released the CPT® 2020 code set, which will be effective Jan. 1, 2020. Among the changes for evaluation and management (E/M) are three new codes for online digital E/M services, which Medicare proposes to reimburse.

Use 99421-99423 for physicians and QHPs
New codes 99421-99423 for physicians and other qualified healthcare professionals (QHP) will all begin with the same phrasing, which sets out the basic requirements: “Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days.”

You’ll choose among the codes based on the time involved:

  • 99421: 5-10 minutes
  • 99422: 11-20 minutes
  • 99423: 21 or more minutes

New AMA CPT® guidelines indicate that these codes are appropriate when a patient initiates a service performed by a physician or other QHPs. The communication should be performed through HIPAA-compliant platforms, like an electronic health record  portal or secure email.

There are two areas that are worth stating, although they may seem obvious once you read them. First, because these codes are in the E/M section, professionals who use these codes must be capable of independently billing E/M services (more on that later). Second, don’t try to use these E/M codes for non-E/M services. For instance, the guidelines state that nonevaluative electronic communication of test results does not qualify for one of these codes.

Calculate minutes for 99421-99423
To count the time for these codes, start the seven-day clock when the physician or QHP first performs personal review of the patient’s question. Add in the time for review of relevant patient records and data, interaction with clinical staff regarding the patient’s problem, developing management plans (including prescriptions and test orders), and further communication with the patient by a digital means that doesn’t fall under another E/M code. Include decision-making, assessment and management by those in the same group practice, too, but don’t count clinical staff time.

Documentation tip: For the medical record, the guidelines instruct you to keep permanent documentation, either electronic or hard copy.

Know when not to bill online services
If you provide the patient with another service around the same time as online communication, the guidelines offer advice on how to handle different scenarios:

  • Online followed by other E/M: If the patient initiates an online E/M service and then presents for a separately reported E/M within seven days, include the online E/M work in the separately reported E/M.
  • E/M followed by online service: If the patient presents for an E/M and then initiates an online inquiry for the same problem or a related one within seven days, don’t report the online service.
  • Online E/M during post-op period: Don’t separately report online inquiries related to a surgery during the postoperative period.

Expect Medicare payment for 99421-99423
According to the 2020 Medicare Physician Fee Schedule (MPFS) proposed rule, Medicare proposes work relative value units (RVU) of 0.25, 0.50 and 0.80, respectively, for the new codes. Work RVUs are a factor in determining payment when combined with practice expense RVUs, malpractice RVUs, the current conversion factor and geographic location.

As a comparison, in the third quarter 2019 MPFS, Medicare assigns 0.48 work RVUs to 99212 Office or other outpatient visit for the evaluation and management of an established patient …

See 98970-98972 for other professionals
The CPT® 2020 code set also will include three new codes (98970-98972) that are almost identical to 99421-99423. The difference is that the descriptors for 98970-98972 state that a “Qualified nonphysician health care professional” performs the service.

Because QHPs may use E/M codes 99421-99423, practices may wonder when it is appropriate to use 98970-98972 for a “qualified nonphysician.” Instructions accompanying 99421-99423 helpfully point you to 98970-98972 for professionals “who may not report the physician or other qualified health care professional E/M services (eg, speech-language pathologists, physical therapists, occupational therapists, social workers, dietitians).”

Watch for G codes for Medicare reporting
If codes 98970-98972 represent services your practice provides, keep an eye on HCPCS Level II 2020 updates for possible alternative codes to report to Medicare. The MPFS 2020 proposed rule states that statutory requirements define which practitioners may bill E/M, so Medicare plans to create G codes with descriptors that refer to “assessment” rather than E/M: “Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days …”

If the proposal goes through, you’ll have one code for 5-10 minutes, one for 11-20 minutes, and one for 21 or more minutes. Medicare proposes to assign work RVUs of 0.25, 0.44 and 0.69 for those G codes, respectively.

Bottom line: As January implementation gets closer, watch to see whether Medicare finalizes the G codes to use in place of 98970-98972 and to see which codes non-Medicare payers will cover, if they decide to reimburse practices for these online digital services.

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