CPT Coding Changes to Know About for 2021

Earlier this fall, the American Medical Association (AMA) released the 2021 Current Procedural Terminology (CPT®) code set. In total for 2021, there are 329 editorial changes, including 206 new codes, 54 deletions, 69 revisions, including the “first major overhaul in more than 25 years to the codes and guidelines for office and other outpatient evaluation and management (E/M) services.” Those changes will become effective on January 1, 2021. 

For a detailed look at all the updates, you can purchase the AMA’s CPT Changes 2021: An Insider’s View. In this post, we highlight several noteworthy ones.

E/M Services

The biggest changes are those to the office and other outpatient E/M services. According to the AMA, these modifications include:

• Eliminating history and physical exam as elements for code selection.
• Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time.
• Promoting payer consistency with more detail added to CPT code descriptors and guidelines.

The new CPT guidelines retain 5 levels of coding for established patients and reduce the number of levels to 4 for office/outpatient E/M visits for new patients. As well, the AMA RVS Update Committee (RUC) updated the values for the office/outpatient E/M visit codes, which will increase payments for these services by Medicare and possibly other payers.

“To get the full benefit of the burden relief from the E/M office visit changes, health care organizations need to understand and be ready to use the revised CPT codes and guidelines by Jan. 1, 2021,” said AMA President Susan R. Bailey, M.D. “The AMA is helping physicians and health care organizations prepare now for the transition and offers authoritative resources to anticipate the operational, infrastructural and administrative workflow adjustments that will result from the pending transition.”

In fact, the AMA is offering an online library of resources that includes a checklist, videos, modules, guidebooks, as well as other tools and resources to help transition to the revised E/M office visit codes and guidelines.

Prolonged Services

Several new codes have been added to bill for prolonged services, involving direct and indirect patient contact provided in various settings beyond usual evaluation and management services.

Direct Patient Contact – Outpatient

Codes 99354-99357 are used when a physician or other qualified healthcare professional provides prolonged service involving direct patient contact that is provided beyond the usual service in either the inpatient, observation or outpatient setting (not including office or other outpatient E/M services).

99354-99355 are used to report the total duration of face-to-face time spent by a physician or other qualified healthcare professional on a given date providing prolonged service in the outpatient setting. 

99354 is used to report the first hour of prolonged service. It should be used only once per date per location, even if the time spent is not continuous. If more than one hour of prolonged service is provided, 99355 is used to report each additional 30 minutes beyond the first hour. 

Prolonged service of less than 30 minutes total duration on a given date is not separately reported. Also, prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Direct Patient Contact – Inpatient

Codes 99356-99357 are used to report the total duration of time spent by a physician or other qualified health care professional providing prolonged service to a patient at the bedside and on the patient’s floor or unit in the hospital or nursing facility.

99356 is used to report the first hour of prolonged service. It should be used only once per date per location, even if the time spent is not continuous. If more than one hour of prolonged service is provided, 99357 is used to report each additional 30 minutes beyond the first hour. 

Prolonged service of less than 30 minutes total duration on a given date is not separately reported. Also, prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Direct Patient Contact – Office or Other Outpatient Services

99417 is the CPT code used to report prolonged time provided on the date of office or other outpatient services. However, in the 2021 Medicare Physician Fee Schedule final rule, the Centers for Medicare and Medicaid Services (CMS) created their own HCPCS code for this prolonged service because, according to their analysis, 99417 lacked “clarity in the code descriptor and the potential for double-counting time.”

When billing Medicare, HCPCS Code G2212 should be used for prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service. 

To report a unit of G2212, at least 15 minutes of additional time must have been attained with or without direct patient contact. Time spent performing separately reported services other than the E/M service is not counted toward the time to report 99205, 99215, and prolonged service time. 

While CPT allows the use of 99358, 99359 for prolonged services on a date other than the date of a face-to-face encounter (see below), CMS does not. So do not bill those to Medicare in addition to an office or other outpatient service. As well, prolonged services of less than 15 minutes total time on the date of the office or other outpatient service (ie, 99205, 99215) also should not be reported.

When following times should be considered when billing Medicare for prolonged service time.

Note, while the CMS has created HCSPC code G2212 for this service, some private payers may require providers to use CPT code 99417. In that case, the following times may be appropriate for billing payers other than Medicare, according to the AMA.

Be sure to contact payers to see which codes they are using.

Indirect Patient Contact

Codes 99358 and 99359 are used when a prolonged service is provided that is neither face-to-face time in the outpatient, inpatient, or observation setting, nor additional unit/floor time in the hospital or nursing facility setting. Codes 99358, 99359 may be used during the same session of an evaluation and management service (except office or other outpatient services) or on a date other than the date of a face-to face encounter, even if the time spent is not continuous. However, according to the description, the indirecton prolonged service must relate to a service or patient where (face-to-face) patient care has occurred or will occur.

99358 is used to report the first hour of prolonged service. If more than one hour of prolonged service is provided, 99359 is used to report each additional 30 minutes beyond the first hour. 

Prolonged service of less than 30 minutes total duration is not separately reported. Also, prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

COVID-19-Related Codes

The 2021 code set also reflects the ongoing COVID-19 pandemic that has ravaged the world in 2020. The following SARS-CoV-2 related CPT codes have been approved and officially published in the 2021 CPT code set, though some have been in use since earlier this year.

• 87635: Added to report infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique. (Effective March 13, 2020.)
• 86318: Revised to report immunoassay for infectious agent antibody(ies) and to be a parent to 86328. (Effective April 10, 2020.)
• 86328: Added to report single step antibody testing for severe acute respiratory syndrome coronavirus 2. (Effective April 10, 2020.)
• 86769: Added as a child code to report multiple-step antibody testing for severe acute respiratory syndrome coronavirus 2. (Effective April 10, 2020.)
• 0202U: Added to report the BioFire® Respiratory Panel 2.1 (RP2.1) test. (Effective May 20, 2020.)
• 87426: Added to report infectious agent antigen detection by immunoassay technique of SARS-CoV and SARS-CoV-2.
  • PLA codes 0223U and 0224U: Added for detection of SARS-CoV-2.
• 86408-86409: Added for reporting coronavirus 2 (SARS-CoV-2) neutralizing antibody screen and titer. (Effective Aug. 10, 2020.)
  • PLA codes 0225U and 0226U: Added for detection of SARS-CoV-2. (Effective Aug. 10, 2020.)
• 99072: Added for the additional supplies and clinical staff time required to mitigate transmission of respiratory infectious disease while providing evaluation, treatment, or procedural services during a public health emergency, as defined by law. 
• 86413: Added for reporting quantitative antibody detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
• 87636: Added for reporting combined respiratory virus multiplex testing for either SARS-CoV-2 with Influenza A&B.
  • PLA codes 0240U and 0241U: Added for detection of SARS-CoV-2, Influenza A and Influenza B.
• 87637: Added for reporting combined respiratory virus multiplex testing for either SARS-CoV-2 with Influenza A&B and RSV.
  • PLA code 0241U: Added for detection of RSV.
• 87811: Added for antigen detection of SARS-CoV-2 by direct optical (i.e., visual) observation.  
• 87301, 87802, and their subsidiary codes: Revised immunology guidelines.
• Accepted addition of code 87428 for reporting multiplex viral pathogen panel using antigen immunoassay technique for SARS-CoV-2 testing along with influenza A and influenza B.
• 91300, 91301: Added to report Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccines.
  • 0001A, 0002A, 0011A, 0012A: Added to report the immunization administration of these vaccines.

Updates to Technology

The updated code set also reflects “the fast pace innovation among digital medicine services,” including new codes for retinal imaging and external extended electrocardiogram (ECG) monitoring. Revisions to codes 92227 and 92228, and the addition of code 92229 will “better support the screening of patients for diabetic retinopathy and increase early detection and incorporation of findings into diabetes care,” according to the AMA.

Advances in continuous cardiac monitoring and detection also have prompted the addition of codes 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, which will replace Category III codes 0295T, 0296T, 0297T and 0298T, which were deleted. According to the AMA, the new continuous cardiac monitoring codes “utilize an innovative algorithmic technology that works in concert with a patch that is much easier to wear for patients and provides more accurate and complete data for physician interpretation.”

ASA RVU Guide and Crosswalk

The American Society of Anesthesiologists’s Relative Value Guide and CROSSWALK Guide for 2021 is now available to order. According to the ASA, this tool “includes the CPT anesthesia codes and cross references all the applicable CPT procedure codes that may be associated with a particular anesthesia code for data analysis and research initiatives.”

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