Insights: Changes in level of service using office visit guidelines

• The American Medical Association (AMA) changed the definitions for codes 99202–99215, effective 1/1/2021
• Medical practices are struggling to accurately apply these new definitions to office visits
• There are significant shifts in the level of service calculated from 2020 to 2021

Both the AMA and CMS said that they didn’t anticipate that levels of service would change with the implementation of new guidelines.  It seemed likely to me – and others – that the levels would change. And based on conversations I’m having with practices, it seems that they are.

Looking for how to interpret data or using time? Watch our FAQ videos on data and time.

Changes for new patient encounters

At first glance, it seems that achieving higher levels of new patient visits would be the result of removing the requirements for history and exam in selecting a level of service. And it’s true, that no one will ever go to a clinician again and say “If only you had one more system in the review systems then this visit would’ve been a level four.” Or, “Only the billing provider can document the history of the present illness.”

But there are two things missing from the new guidelines that will have the effect of lowering the level of new patient visits. The first is that the concept of new to the examiner is removed from the guidelines and the second is that new to the examiner with workout planned. In the 1995 and 1997 guidelines, these two issues often moved the number of problems to moderate or high.

Now, using the new guidelines and the first element, the number and complexity of problems addressed, both of those are gone. Problems relate to the patient, not the examiner. New or existing is removed. And, work up is accounted for in data. Using this first element, some problems that were “new to the examiner,” i.e., moderate, are now “acute, uncomplicated illnesses,” i.e., low in this first element.

Changes in visit level for common scenarios

Using the 1995/1997, required two of three or three of three of the key components of history, exam and MDM. The scenarios below assume that the level of history and exam required for 1995/1997 visits in 2020 are met. They describe MDM only.

As you review these examples, you’ll see that some visits code at a higher level now, and some at a lower level. 

Sample visits

• Visit #1 – Acute problem with prescription drug management: ASSUME history and exam meet requirements: of course, most kids with otitis wouldn’t have a comprehensive history/exam. This is showing how MDM works.

4 year-old brought in by her Dad. Dad reports child complains her ear hurts, she has a fever and she is up at night crying. Physician diagnoses otitis media, gives antibiotics.

Using the 1995/1997 guidelines, the complaint was new to the examiner.

Using the 2021 guidelines, the problem relates to the patient, and is an acute, uncomplicated illness.

 

• Visit #2 – One problem, not in good control

Patient with ADHD presents for follow up and prescription renewal. Reports symptoms are not well -controlled. Difficulty concentrating and with task completion. Assessment:  ADHD not at goal. Prefers to continue same dose of medication, but gave him a referral for therapy.”

Using the 1995/1997 guidelines, one established problem (to the examiner) not stable was low complexity.

Using the 2021 guidelines, one chronic problem not at goal is moderate under the number and complexity of problems addressed.

 

• Visit #3 – One problem, seen by specialist, stable chronic condition

Patient with lupus seen for six month visit by rheumatologist. Labs were ordered at prior visit, and are reviewed at this visit. Patient’s symptoms under good control, at goal. Medications renewed.

Using the 1995/1997 guidelines, one established problem in good control was minimal in the column for number of problems. One or ten lab tests was one point for lab.

Using the 2021 guidelines, one chronic problem, stable, is low complexity for problems. Because the doctor ordered the labs at a prior visit, no credit is given for reviewing them at this visit.

• Visit #4 – Two stable problems

Patient with hyperlipidemia and hypertension. Both are at goal for patient. Nurse practitioner reviews two labs, ordered over the phone the prior week. Renews medications.

Using the 1995/1997 guidelines, two stable problems was limited in the number of diagnoses/management options, one point each. Two labs counts a one point for lab.

In 2021, two stable chronic problems are moderate in the number and complexity of problems addressed.

Additional Resources

• See our E/M changes for 2021 roadmap for a complete list of resources on this topic.

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