code set for providers to report procedures, services, drugs, and devices furnished by physicians and other non-physician practitioners, hospital outpatient facilities, ambulatory surgical centers, and other outpatient facilities. This system includes Current Procedural Terminology Codes, which the American Medical Association developed and maintains. Effective January 1, 2021, CMS is consolidating and increasing payment for the Medicare-specific add-on code, HCPCS code GPC1X, for office/outpatient E/M visits for primary care and non-procedural specialty care into a single code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. This code is not intended to reflect a difference in payment by enrollment specialty, but rather a better recognition of differences between kinds of visits. Effective January 1, 2021 CMS is aligning E/M coding with changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office/ outpatient E/M visits, which: • Retains 5 levels of coding for established patients, reduces the number of levels to 4 for office/outpatient E/M visits for new patients, and revises the code definitions • Revises the times and medical decisionmaking process for all of the codes, and requires performance of history and exam only as medically appropriate • Allows clinicians to choose the E/M visit level based on either medical decision making or time For more information, review the CY 2021 Physician Fee Schedule Web Page and the Medicare Learning Network®(MLN) Connects Physician Fee Schedule Final Rule: Understanding 4 Key Topics Call transcript, recording and presentation. Evaluation and Management Services Guide MLN Booklet Page 6 of 23 MLN006764 February 2021 International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) ICD-10-CM codes – A code set providers use to report medical diagnoses on all types of claims for services furnished in the United States (U.S.). ICD-10-PCS codes – A code set facilities use to report inpatient procedures and services furnished in U.S. hospital inpatient health care settings. Use HCPCS codes to report ambulatory services and physician services, including those physician services furnished during an inpatient hospitalization. E/M SERVICES PROVIDERS To receive payment from Medicare for E/M services, the Medicare benefit for the relevant type of provider must permit him or her to bill for E/M services. The services must also be within the scope of practice for the relevant type of provider in the State in which they are furnished. SELECTING THE CODE THAT BEST REPRESENTS THE SERVICE FURNISHED Billing Medicare for an E/M service requires the selection of a Current Procedural Terminology (CPT) code that best represents: ● Patient type ● Setting of service ● Level of E/M service performed Patient Type For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider. New Patient: An individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous 3 years. Established Patient: An individual who receives professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous 3 years. Setting of Service E/M services are categorized into different settings depending on where the service is furnished. Examples of settings include: ● Office or other outpatient setting ● Hospital inpatient ● Emergency department (ED) ● Nursing facility (NF) Page 7 of 23 MLN006764 February 2021 Evaluation and Management Services Guide MLN Booklet Level of E/M Service Performed The code sets to bill for E/M services are organized into various categories and levels. In general, the more complex the visit, the higher the level of code you may bill within the appropriate category. To bill any code, the services furnished must meet the definition of the code. You must ensure that the codes selected reflect the services furnished. The three key components when selecting the appropriate level of E/M services provided are history, examination, and medical decision making. Visits that consist predominately of counseling and/or coordination of care are an exception to this rule. For these visits, time is the key or controlling factor to qualify for a particular level of E/M services. History The Elements Required for Each Type of History table shows the elements required for each type of history. You can find more information on the activities comprising each of these elements on pages 7 and 8. To qualify for a given type of history, all four elements indicated in the row must be met. Note that as the type of history becomes more intensive, the elements required to perform that type of history also increase in intensity. For example, a problem focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), while a detailed history requires the documentation of a CC, an extended HPI, plus