Part 5: New 2020 CPT Codes | Modifiers, Category III, Evaluation and Management

This is Part 5 of a five part series on the new 2020 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.

This series includes:

  • Part 1 - 5 new integumentary CPT codes added with 4 deletions and 1 revision.
  • Part 2 - 11 new musculoskeletal CPT codes added with 1 deletion and 0 revisions.
  • Part 3 - 11 new cardiovascular CPT codes added with 8 deletions and 2 revisions.
  • Part 4 - 3 new digestive system codes with 1 deletion and 2 revised; 1 revised urinary system codes with new category III codes; 6 new with 20 deleted nervous system codes with 3 revisions; 2 new eye codes with 3 revisions; and finally a new category III auditory code.
  • Part 5 - summary of Modifiers, Category III codes, Radiology, Medicine, Laboratory and Pathology, and Evaluation and Management.


Two modifiers were revised:

Modifier 50 revised:
Do not append on add-on codes
Documentation throughout CPT has been standardized to state to report the add on code TWICE if done bilaterally.

Modifier 63 revised:
Added Medicine codes that are invasive cardiovascular procedures to the list for which this modifier can be assigned. See CPT code book for the list of these procedures.


Category III Codes

Category III CPT codes are released semi-annually,  in January and July.  There are 51 new, 11 deleted and 1 revised Category III codes.  Review pages 776-808 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 is a new series of codes for Islet cell transplantation, 0584T-0586T.  Use Category III codes first before regular surgical CPT codes.



For radiology there are 12 new codes, 15 deleted, and 18 revised.  There are many revised codes.  There is an add on code for small intestine follow through study.  Also there are new myocardial imaging codes.  Please review this section if you assign these codes. Most of these codes however and entered into the chargemaster.



For this section there are 47 new codes, 21 deleted, and 10 revised Medicine CPT Codes.

There are new influenza and meningococcal vaccine codes along with new/revised biofeedback, ophthalmology, and EEG codes.  In addition, there are new “Digital Evaluation and Management” codes that all professional fee coders should review.


Laboratory and Pathology

There are 89 new codes, 5 deleted and 5 revised codes. Most of the new codes and revisions involve molecular pathology, which is a growing field.  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

There are new codes for online digital evaluation that are PATIENT INITIATED.

  • 99421 Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
  • 99422 … 11-20 minutes
  • 99423 … 21 or more minutes

These codes are intended for PATIENT-INITIATED digital communications (such as those through patient portals) that require a clinical decision that would otherwise have been typically provided in the office.   (NO CLINICAL STAFF TIME CAN BE COUNTED!)

If within 7 days of the initiation of online E/M services, a separately reported E/M visit occurs, then the MD/QHP work devoted to the online digital E/M service is incorporated into the separately reported E/M visit.  (It is additive of time for a time based E/M visit or additive of MDM for other.)

This code has been deleted:  99444 Online evaluation and management service provided by a physician or other  qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network

There are new codes for self-measured blood pressure:

  • 99473 Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration

This is for the patient initially receiving the device with training.

Only reported ONCE per DEVICE.

  • 99474 Self-measured blood pressure using a device validated for clinical accuracy; separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient

The self-measured blood pressure readings helps to avoid “white coat hypertension.”

The code is for MD reviewing individual readings and telling clinical staff what to tell patient.


There is one updated and one new remote monitoring code:

▲99457 Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes

+●99458 … each additional 20 minutes (List separately in addition to code for primary procedure)

Must be a medical device as defined by FDA and must be ordered by an MD or QHP.

These codes are for use of device monitoring that do not currently have a separate CPT code for use.

Example, pt with heart failure with remote physiological monitoring.


E/M for FY2020: For established patients history and exam, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed.  CMS will allow physicians, physician assistants, and advanced practice registered nurses (APRN) to review and verify—through a simple “verify sign and date” process—rather than re-document notes made in the medical record by other physicians, residents, medical, physician assistants and APRN students, nurses, or other members of the medical team.

CMS also defined the APRN group of providers, which includes nurse practitioners, clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists.

Additionally, we are clarifying that for new and established patients chief complaint and history, (and exam, checking) practitioners need not re-enter in the medical record information that has already been entered by ancillary staff or the beneficiary or medical students or residents. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information and then sign and date.


Beginning in CY 2021: CMS will implement payment, coding, and additional documentation changes for E/M office/outpatient visits, 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. (See next slide for additional discussion.)
    • 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.
  • Previously proposed collapsing the five tier payment into two blended rates however with provider push back, CMS backtracked those changes.
  • 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: November 15, 2019
    • December 31, 2019 – $36.04
    • January 1, 2020 – $36.09
    • January 1, 2020 – about a 0.14 percent increase
    • Anesthesia conversion factor decreases from $22.27 to $22.20.
  • Principal Care Management:  Only one practitioner can bill; need to get consent to bill by law, table in the rule.  Two services:
    • G2064 – care management services furnished by the billing practitioner – $92
    • G2065 – care management services furnished by the CLINICAL STAFF under the billing practitioner’s  supervision – $40
  • G2061 (qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the seven days; 5-10 minutes).
  • CMS is finalizing the addition of three new telehealth codes for opioid treatment as part of its new bundled care program for treatment of opioid use disorders:
    • G2086, office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month
    • G2087, …; at least 60 minutes in a subsequent calendar month
    • Add-on code G2088, …; each additional 30 minutes beyond the first 120 minutes.
  • Chronic Care Mgmt. G0258 (Add-on to 99490) each additional 20 min clinical staff time after initial 20 min, $38;  maximum 2 billings
  • Professional Fee coders should review the total list of G codes.
  • CMS will pay for office based Opioid treatment Program benefit if requirements met.  G2086 70 min first month; G2087 60 minutes G2088 each additional 30 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.

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