Part 5: New 2021 CPT Codes | Modifiers, Category III, Evaluation and Management, etc.

This is Part 5 of a five part series on the new 2021 CPT codes.  For the remaining areas we will just briefly summarize the section.  Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.

Modifiers

 No changes were made to modifiers.

Category III Codes

Category III CPT codes are released semi-annually,  in January and July.  There are 48 new, 23 deleted and 1 revised Category III codes.  Review pages 841-876 of CPT book which indicate the new codes delineated by a red circle.   Many of the Category III codes not already discussed in the previous 4 parts of this series involve more diagnostic and testing procedures across all specialties.  Of note are the following new category III codes that may be of interest to coders:

• 0600T Ablation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous
• 0601T 1 or more tumors per organ, including fluoroscopic and ultrasound guidance, when performed

        (Do not report 76940, 77002)

Electroporation, or electropermeabilization, is a microbiology technique in which an electrical field is applied to cells in order to increase the permeability of the cell membrane, allowing chemicals, drugs, or DNA to be introduced into the cell.

• 0602T Glomerular filtration rate (GFR) monitoring, transdermal, including sensor placement and administration of a single dose of fluorescent pyrazine agent
• 0603T Glomerular filtration rate (GFR) monitoring, transdermal, including sensor placement and administration of MORE THAN one dose of fluorescent pyrazine agent, each 24 hours

The below codes may be already on the chargemaster however coders may be asked to code them:

• 0604T – 0606T Optical Coherence Tomography (OCT) of retina with initial device, remove surveillance and review and interpretation
• 0607T – 0608T Remote monitoring of external continuous pulmonary fluid, or analysis of data
• 0609T – 0612T Magnetic resonance spectroscopy of discogenic pain, transmission, postprocessing, interpretation and report
• 0633T – 0638T CT of breast, including 3D rendering, unilateral, bilateral, with or without contrast material
• 0639T Wireless skin sensor thermal anisotropy measurements and assessments of flow in cerebrospinal fluid shunt, including ultrasound.

There are more Category III codes that have not been reviewed in this series. Please review to make sure your facility does not report these other Category III codes. They are also hard to find in an encoder so please remember to look at this section in the actual CPT tabular.

Radiology

For radiology there are 2 new codes, 2 deleted, and 6 revised.  There is a new code 71271 for CT thorax low dose for lung cancer screening and a new code 76145 for medical physics dose evaluation for radiation exposure.  There were also CT imaging and urography codes revised.  Please review this section if you assign these codes. Most of these codes however and entered into the chargemaster.

Medicine

For this section there are 18 new codes, 9 deleted, and 4 revised Medicine CPT Codes.

There is a new rabies vaccine code, new vestibular evoked myogenic potential testing codes and new external electrocardiography recording codes.  Coders should review these codes to see if they are assigned by the chargemaster or by the coder.

Laboratory and Pathology

There are 118 new codes, 8 deleted and 12 revised codes. Most of the new codes and revisions involve new drug assays and oncology lab tests.  Since many of these codes are inputted in the pathology or laboratory departments via chargemaster, the hospital will want to be sure the chargemaster is up to date and personnel in these departments are aware of the updates.

Evaluation and Management

Office and Other Outpatient E/M for FY2021:

CMS will implement payment, coding, and additional documentation changes for E/M office/outpatient visits, 99202-99215, (99201 was deleted) specifically:

• Allow physicians to choose their level based on whether their documentation is based on Medical Decision Making (MDM) or Total Time essentially eliminating history and physical exam as elements for code selection (but they still need to be documented as medically appropriate):
• MDM: The Workgroup did not materially change the three current MDM sub-components, but did provide extensive edits to the elements for code selection and revised/created numerous clarifying definitions in the E/M guidelines.
• Time: The definition of time is minimum time, not typical time, and represents total physician/qualified health care professional (QHP) time on the date of service. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services like care coordination. These definitions only apply when code selection is primarily based on time and not MDM.
• Modifications to the criteria for MDM: The Panel used the current CMS Table of Risk as a foundation for designing the revised required elements for MDM. Current CMS Contractor audit tools were also consulted to minimize disruption in MDM level criteria.
• Removed ambiguous terms (e.g. “mild”) and defined previously ambiguous concepts (e.g. “acute or chronic illness with systemic symptoms”).
• Also defined important terms, such as “Independent historian.”
• Re-defined the data element to move away from simply adding up tasks to focusing on tasks that affect the management of the patient (e.g. independent interpretation of a test performed by another provider and/or discussion of test interpretation with an external physician/QHP).
• Deletion of CPT code 99201: The Panel agreed to eliminate 99201 as 99201 and 99202 are both straightforward MDM and only differentiated by history and exam elements. So there will be 4 New Patient levels and 5 Established Patient levels.
• Creation of a shorter prolonged services code: The Panel created a shorter prolonged services code that would capture physician/QHP time in 15-minute increments. This code would only be reported with 99205 and 99215 and be used when time was the primary basis for code selection.
• Conversion factor for physician services:
• December 31, 2020 – $36.09
• January 1, 2021 – $32.41 – About a $3.68 decrease from 2020  (10% drop)
• Anesthesia conversion factor decreases from $22.20 to $20.05.

New prolonged services add on code:

• ● +99417) Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required 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 of total time (List in addition to 99205, 99215 for services) (NON MEDICARE)
• Read extensive notes for this code.
• Prolonged services of less than 15 minutes total time is not reported on the date of office or other outpatient service when the highest level is reached (99205, 99215)
• Only used when time is used to select 99205/99215.
• Tables in the CPT book show examples and codes to use.
• NOTE: CMS wants G2212 instead of 99417 which has different requirements than 99417: 
• ● G2212 – 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; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact
• (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
• (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416).
• (Do not report G2212 for any time unit less than 15 minutes).
• Requires the visit to exceed the maximum time for 99205 and 99215.

• G2211 – (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 condition or a complex condition.

[Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established]).

• CMS estimates that the new add-on code will be appropriate for 90% of E/M office visit encounters, the agency stated in the final rule.
• Note that the code can be reported with new patient visits: In the final rule CMS noted that it had accidentally excluded new patients from the descriptor in the proposed rule released earlier this year.

• G2252 – for a “brief communication technology-based service (e.g., virtual check-in)” for established patients only. The code would be priced at the same amount as CPT telephone visit code 99442 and would cover an 11-20-minute “medical discussion,” similar to that code.

• The code would be used for cases “when the acuity of the patient’s problem is not necessarily likely to warrant a visit, but when the needs of the particular patient require more assessment time from the practitioner,” CMS states in the rule.
• For example, the service applies when the patient reports an exacerbation of an ongoing problem and wants to know whether a face-to-face office visit is warranted, CMS states. The agency stated that it does not consider a telephone visit to be a substitute for an E/M service but instead “an assessment to determine the need for one.”
• Code G2252 will therefore be considered a communications technology-based service (CTBS) similar to a virtual check-in, not a telehealth service. Like the CPT phone codes, it will not be separately reported if the call occurs within seven days after a previous in-person visit or within 24 hours “or soonest available appointment.”

A new code for CC and CCC was added: 

• 99439 each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

• (Chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately)
• At least a full 20 minutes of ADDITIONAL time!
• 3 revised codes (99490, 99487, 99489) Things that cannot be reported with Care Management (CM):
• With each other
• End Stage Renal Disease
• Care plan oversight
• Medication therapy management

Transitional Care Management Services revised guidelines:

• Revised Guidelines (99495, 99496)
• “We note that the minutes counted for TCM services cannot also be counted towards other services.” (2021 PFS NPRM)
• Each minute of service time is counted toward only one service. Do not count any time and activities used to meet criteria for another reported service. However, time of clinical staff and time of a physician or other qualified health care professional are distinct when each provides a distinct, separately reportable service to the same patient during the same period of time ( eg , calendar month).

For 2021, CMS replaced G2061-G2063 with codes 98970-98972:

98970 – Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

      98971 – 11-20 minutes

      98972 – 21 or more minutes

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.