E&M Codes 2021: Good News, for a Change

Just about exactly eight years ago, I wrote a series of posts that began with this paragraph:

If you’re a psychiatrist (or psychiatric RNCS) in the US reading this, you are almost certainly aware that all of our billing codes changed on Jan 1, 2013.  If you are like most of the psychiatrists I know—at least in private practice—you are at least somewhat freaked out by this.  If so, keep reading.  If not—for example, if you’re not a psychiatrist in the US—stop reading this immediately and go do something more interesting, like… well, like just about anything other than memorizing a phone book.  (There used to be things called phone books…  never mind.)

Unlike 2013, the billing codes themselves have not changed, but as of January 1, 2021, the documentation requirements for these codes have gotten significantly less complex and onerous. Like then, this post should be of no interest to you if your are not a US psychiatrist or psychiatric nurse. But if you are—and especially if a significant portion of your practice is psychotherapy—the situation is very different from 2013 because these changes are:

  • good news
  • not widely publicized

The 2013 codes could be chosen based on either time or complexity. That is still the case, but:

  • When choosing a code based on time, you can now count total time, not just face-to-face time talking to the patient. That means you can include the time it takes to write your note, review previous notes or records, speaking with other providers, etc. The time periods are somewhat longer, but this definitely looks like a win.
  • When choosing a code based on complexity, the choice is now based only on medical decision-making (MDM); before it was based on MDM and also required documenting certain combinations of history and exam elements. This is huge.

The changes for complexity-based codes are particularly significant for physician or nurse psychotherapists, because if you are using a psychotherapy add-on code (90833, 90836, 90838), the E&M code that you are adding on to must be based on complexity.

The AMA has a set of slides with details about the changes.

Time-based criteria

Time ranges for follow-up visits:

CodeTotal time
99211< 10″
9921210-19″
9921320-29″
9921430-39″
9921540-54″
Slides 25-29 of https://www.ama-assn.org/system/files/2020-04/e-m-office-visit-changes.pdf

For follow-up visits of 55 minutes or longer, you can bill the code “99XXX” (seriously, that is what it seems to be called) once for each additional 15″ block. So 55-59″ is billed as 99215 + 99XXX, and 70-84″ is billed as 99215 + 2 units of 99XXX.

Time ranges for initial visits:

CodeTotal time
9920215-29″
9920330-44″
9920445-59″
9921560-74″
Slides 21-24 of https://www.ama-assn.org/system/files/2020-04/e-m-office-visit-changes.pdf

As above, for initial visits with total time 74″ (are your write-ups as time-consuming as mine?), you can bill one unit of 99XXX for each additional 15″.

Of course, make sure that your note clearly documents the total time.

Complexity-based criteria

Here is a link to a table which gives a clear overview of the criteria for MDM complexity.

The rows in the table address particular codes (such as 99213, 99214, 99215). Each row has three columns of “Elements of Medical Decision Making.” For a particular row to work, two of these three columns must apply. The first column is “Number and Complexity of Problems Addressed.” The second is “Amount and/or Complexity of Data to be Reviewed and Analyzed.” The third is “Risk of Complications and/or Morbidity or Mortality of Patient Management.” The second column has to do mostly with ordering and interpreting tests; as I read it, it is rarely relevant to our coding. So to use a particular code, we just need to make sure that columns 1 and 3 apply.

The 99213 applies to patients with, at a minimum, one stable chronic illness, and “low risk of morbidity from additional diagnostic testing or treatment.” If you are a psychiatrist doing psychotherapy, this applies to every visit with a patient. Presumably you need to document which illness you are treating.

For 99214, there must be “moderate risk of morbidity from additional diagnostic testing or treatment”; as an example, they cite “prescription drug management.” If someone is stable on their medications and you are merely prescribing a refill, I would not guess that this applies. But if you are actively considering a medication change with the patient, your action (or inaction) does have at least a moderate risk of morbidity, either by introducing new side-effects, or by worsening or failing to improve the patient’s condition (especially in the case of inaction or medication reduction). You can meet the criteria in the first column with either “one or more chronic illnesses with exacerbation, progression, or side-effects of treatment,” or “two or more stable or chronic illnesses.” Given the ubiquity of comorbidity in our diagnostic system, this should be pretty much automatic.

Any time you seriously consider hospitalizing a patient, you should be able to use 99215. Column one needs a “chronic illness with severe exacerbation, progression, or side-effects of treatment” or an “acute or chronic illness or injury that poses a threat to life or bodily function.” Column three refers specifically to “decision regarding hospitalization.”

Exactly the same criteria apply for the corresponding initial visit codes (99203, 99204, and 99205).

Given the simplicity of MDM system, I suspect that psychiatrists will be better off coding follow-up visits based on MDM instead of time, even when there is no psychotherapy add-on. For initial visits where hospitalization is not a consideration, time-based coding may allow you to bill using 99215 (with possible additional units of 99XXX).

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