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December 16, 2019

2019 coding/reimbursement highlights

AGA coding and reimbursement physician volunteers have been busy this year reviewing proposals and providing feedback on Evaluation and Management (E/M) coding and payment changes that will take place in 2021.
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E/M coding and guidelines are about to undergo the most significant changes since their implementation. The changes to guidelines and coding for new and established office/outpatient visits (CPT codes 99202-99205, 99211-99215) won’t officially take place until Jan. 1, 2021, but they are so significant that the AMA has already released a preview of the CPT 2021 changes.

In addition to coding and guidelines changes the AMA made in response to pressure from the CMS to simplify documentation requirements for E/M, CMS proposed payment changes for the new and established office/outpatient E/M codes. AGA physician representatives have been working with our sister GI societies and the AMA for the past two years to convince CMS to walk back proposed changes to collapse E/M levels and payments which would have resulted in significant payment cuts to level 4 and 5 E/M visits. CMS published in the 2020 Medicare Physician Fee Schedule final rule that it will adopt the AMA’s recommended relative values for 2021 CPT E/M codes which include modest payment increases beginning Jan. 1, 2021.

CMS also plans to add two new add-on codes as of Jan. 1, 2021 that can be used in addition to the E/M codes. CMS said it created the add-on codes because the agency felt the E/M codes do not recognize additional resource costs that are an inherent part of some office/outpatient E/M visits.

  • 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).
  • 99XXX – Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services).

GPC1X will be added in 2021 to recognize the additional resource costs associated with performing either a visit that is part of ongoing care of a patient’s single, serious, or complex condition or a primary care visit. It can be billed with all levels of E/M office/outpatient codes. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).

99XXX will be added in 2021 for extended office/outpatient E/M visits to report all prolonged time spent on the date of the primary office/outpatient E/M visit code, which is the 24-hour period for the date of service reported for the primary office/outpatient E/M visit code. CMS plans to reimburse 99XXX 0.61 RVUs (about $22).

Make time in 2020 to connect with your coders or contact your medical billing company and create a plan for training physicians and staff for the changes for a smooth transition on Jan. 1, 2021. With changes this big, we encourage you to prepare early.

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