CMS Proposes to Reverse E/M Stance to Align with AMA Revisions

August 6th, 2019 - Wyn Staheli, Director of Research
Categories:   CPT® Coding   HCPCS Coding   Evaluation & Management (E/M)  
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On July 29, 2019, CMS released their proposed rule for the Medicare Physician Fee Schedule for 2020. Last year’s final rule “finalized the assignment of a single payment rate for levels 2 through 4 office/outpatient E/M visits beginning in CY 2021.” It also changed some of the documentation requirements (e.g., choice of time or Medical Decision Making [MDM] to determine code level selection). But these are things we already knew. What is new is that they are proposing to eliminate that single payment rate for levels 2-4.

Without major changes from the AMA regarding the reporting of these services, it didn’t really make sense for CMS to be different from everyone else. That’s why the American Medical Association’s (AMA) February 2019, CPT Editorial Panel information is significant. The AMA met to approve revisions to the E/M office or other outpatient visit reporting guidelines (codes 99201-99215) as requested by CMS. The proposed rule states the following about this meeting (emphasis added):

Effective January 1, 2021, the CPT Editorial Panel adopted revisions to the office/outpatient E/M code descriptors, and substantially revised both the CPT prefatory language and the CPT interpretive guidelines that instruct practitioners on how to bill these codes. The AMA has approved an accompanying set of interpretive guidelines governing and updating what determines different levels of MDM for office/outpatient E/M visits. Some of the changes made by the CPT Editorial Panel parallel our finalized policies for CY 2021, such as the choice of time or MDM in determination of code level. Other aspects differ, such as the number of code levels retained, presumably for purposes of differential payment; the times, and inclusion of all time spent on the day of the visit; and elimination of options such as the use of history and exam or time in combination with MDM, to select code level.

The proposed rule said that they are revising their policies based on AMA’s revised language for these codes because they feel it will reduce the administrative burden more than the CMS’ 2019 finalized revisions. CMS will still assign a separate payment for extended visits using the new CPT code (99XXX) instead of the previously proposed HCPCS code GPRO1.

Note: Throughout this document, code 99XXX means that there will be a new CPT code assigned which begins with 99. The actual code number has not yet been released by the AMA and they are using XXX as a placeholder.

The proposed rule further states:

...history and exam would no longer select the level of code selection for office/outpatient E/M visits. Instead, an office/outpatient E/M visit would include a medically appropriate history and exam, when performed. The clinically outdated system for number of body systems/areas reviewed and examined under history and exam would no longer apply, and these components would only be performed when, and to the extent medically necessary and clinically appropriate. Level 1 visits would only describe or include visits performed by clinical staff for established patients.

Levels 2-5 will be reported based on either the level of MDM (per the new AMA guidelines) or the total time spent by the healthcare provider which includes both face-to-face and non-face-to-face time. It is important to note that the AMA has published new time requirements for each code (see References below).

Prolonged E/M services (99XXX), with or without direct patient contact, are reported with one unit for each 15 minutes beyond the original 54 minutes for established patients (99215) or 74 minutes for new patients (99205) and cannot be reported with 99212-99214 or 99202-99204. According to the table below, once the documented time exceeds even one (1) minute, it is eligible for one unit of the prolonged E/M code. In order to report a second unit of prolonged E/M time for this category, the first unit (15 minutes) must be exceeded.

The following table from the proposed rule summarizes the new time reporting methodology for office and other outpatient prolonged E/M services (new and established):

Established Patient (99215)

New Patient (99205)

Addon Code(s)

40-54 minutes 60-74 minutes none
55-69 minutes 75-89 minutes 99XXX (x1)
70-84 minutes 90-104 minutes 99XXX (x2)
85 or more minutes 105 or more minutes 99XXX (x3 or more for each additional 15 minutes)

Other Important Changes

The following are other E/M changes for Office/Outpatient visits which will be (or are proposed to be) effective as of January 1, 2021:

  • Code 99201 will be deleted.
  • Elimination of the use of history and/or physical exam to select the correct code level, The exception is that if neither are documented and medical necessity would warrant them being performed and documented, it could trigger additional review.
  • Pre-, Intra-, Post-Service time changes. The new AMA guidelines state that time spent in an E/M service includes all time spent 3 days prior to, or 7 days after it. If a patient calls in to the office to speak with a provider about a medical condition and that telephone conversation results in an appointment for an E/M service that occurs within 3 days of the call, it is not billable as a virtual communication service (G2012, 99441-99443), but rather would be incidental to (or part of) the resulting E/M service. The same would apply if the communication took place within 7 days following the initial E/M service.

    The following table summarizes the Relative Value Update Committee (RUC) recommendations (in minutes) on the breakdown of time associated with pre-, intra-, and post-service work related to the following E/M services and the actual total time (based on physician surveys) versus the RUC-recommended time. For example, for a 99213 visit which has 30 minutes of actual total time, the intra-service (main work of the service) takes approximately 20 minutes and the rest is spent in pre-service work (5 minutes) and post-service work (5 minutes).


    Service Times

    Actual Total Time RUC Recommended Total Time
    Pre- Intra- Post-
    99202 2 15 3 20 22
    99203 5 25 5 35 40
    99204 10 40 10 60 60
    99205 14 59 15 88 85
    99211   5 2 7 7
    99212 2 11 3 16 18
    99213 5 20 5 30 30
    99214 7 30 10 47 49
    99215 10 45 15 70 70
  • Prolonged E/M without Direct Patient Contact codes 99358-99359 are no longer reportable with Office/Outpatient E/M visits (99202-99205, 99211-99215). However, according to the proposed rule, it is currently unclear whether these codes may be reported instead or in addition to E/M codes or the new E/M prolonged E/M code (99XXX). It is also unclear “...whether the prolonged time would have to be spent on the visit date, within 3 days prior or 7 days after the visit date, or outside of this new 10-day window relevant for the base code."
  • Revaluation: Since time components have changed, there will be new RVUs for these services.
    • Work RVUs: The following table shows the 2019 work RVUs along with the proposed new RVUs for 2021:
      Code 2019 work RVU 2021 work RVU
      99202 0.93 0.93
      99203 1.42 1.60
      99204 2.43 2.60
      99205 3.17 3.50
      99211 0.18 0.18
      99212 0.48 0.70
      99213 0.97 1.30
      99214 1.50 1.92
      99215 2.11 2.80
      99XXX (prolonged E/M) n/a 0.61
    • Practice expense RVUs will likely be lowered as well; because they are proposing to remove equipment item ED021 (computer, desktop, with monitor) in the overhead costs.
  • Specialty-Specific Coding: CMS still feels that even with these revisions, there are certain specialties which have greater complexity when it comes to E/M services. Therefore, they are proposing the following add-on code (which is different than the 2019 final rule and valued similarly to the behavioral health interactive complexity code 90785):
    • GPC1X - 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. (Addon code, list separately in addition to office/ outpatient evaluation and management visit, new or established)


  • Code GPC1X is not a real code. The actual code has not yet been released by CMS.
  • Previously there were distinct specialties included in the code description(s) (e.g., endocrinology, pulmonology, cardiology, psychiatry, primary care). It will be important to carefully follow any new guidelines as to applicable specialties.


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

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