2021: New Codes to Know

Most of us are very excited to leave the year 2020 behind us. What we need to remember is that, even in the midst of COVID19, the American Medical Association has not put their coding changes on hold. It is important to maintain a grasp on any and all changes coming in 2021. For the optometric world, that means a few significant code changes. 

 Of all the changes coming to Coding Procedural Terminology (CPT), one of the largest, as it affects our industry, is the removal of CPT code 99201. This code has long been used to evaluate and manage new patients, requiring a problem-focused history, a problem focused examination, and straightforward medical decision-making. As of January 1, 2021, this code will no longer be in use. The similar code, 99211, used for established patients, will be maintained as a usable CPT code. 

 The next most important change in codes, pertaining to optometry, is the inclusion of time as a method to determine the appropriate 99XXX evaluation and management, or E/M, code. By documenting the amount of time spent with a patient, including pre-evaluation and referral coordination or communication with other professionals, you may determine the appropriate E/M code. In order to appropriately manage this change, it is of the utmost importance to document everything clearly and appropriately. Should an evaluation take longer than the amount of time, as dictated below, there are also prolonged services that may be coded separately on the same claim as the 99XXX code.

Prolonged service codes provide an added level of complexity to claims, and must be used with great attention to detail. To specify prolonged services, it is most efficient to use 99356, which may be added in conjunction with 99XXX codes. 99356 is described as a “prolonged service, inpatient or observation setting; first hour”^[1] and 99357 indicates each additional 30 minutes. These codes both require at least 30 minutes of face-to-face time between the provider and patient, as well as the amount of time the medical unit spends with that patient.

These prolonged service codes may be filed as a separate line item on the claim form, and must be strongly documented in the patient’s medical record. By specifically recording time spent face-to-face with a patient, it is possible to change the billable code to a higher level, which will, in turn, create a higher reimbursement. Again, remember the importance of documentation of time. Should a claim be flagged for audit, it is necessary to provide specific reasoning for billing for prolonged services.

 Many changes may take place over the years with CPT codes as they apply to optometry and ophthalmology, and these guidelines are ever changing. It is strongly recommended that you stay up to date on coding requirements through organizations like the AMA, AOA, and others; continuing education is constantly necessary, not just for treatment of your patients, but for compliance with AMA guidelines with medical billing. Failure to maintain a firm grasp on proper coding can result in audits that create great time and financial strain. It is recommended that all doctors and billing staff spend the time necessary to ensure full understanding of the changes to E/M guidelines to avoid any mishandling of insurance claims moving on in 2021 and beyond.

SOURCES:

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

https://www.aap.org/en-us/Documents/coding_prolonged_services.pdf

[1] https://www.aap.org/en-us/Documents/coding_prolonged_services.pdf