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  • Cutting the Red Tape—Evaluation and Management (E/M) Coding Changes for 2021:
    What Neurosurgeons Need to Know

    Author: Katie Orrico, esq.

    NOTE: This article has been edited from the original print edition, to reflect updated information. Specifically, Table 2 now contains the correct times for time-based E/M coding, and the article includes details about the passage of the Consolidated Appropriations Act, 2021, which prevented neurosurgery’s 6% Medicare payment cut. 

    For decades, physicians have struggled with burdensome documentation requirements for office and outpatient visits—otherwise known as evaluation and management (E/M) services. The E/M documentation guidelines used by the Centers for Medicare & Medicaid Services (CMS) are a complex matrix of check-boxes and documentation requirements that focuses on information that is not always relevant to the service provided and the medical decision-making necessary for patient care. The medical community was unified in its desire to reduce the burden of documenting E/M services.

    Substantial changes in how neurosurgeons report office and outpatient clinic visits were implemented beginning on Jan. 1, 2021. These changes will affect all practicing neurosurgeons, regardless of sub-specialty or practice type. Born out of burden reduction efforts in Congress (e.g., the House Ways and Means Committee’s “Red Tape Relief Project”) and CMS’ “Patients over Paperwork” initiative, the new E/M coding rules aim to replace the byzantine and onerous check-box system with one that focuses on clinical documentation of the care provided to the patient.

    After reviewing options with CMS, the AMA CPT® Editorial Panel revised the E/M CPT codes developing a new set of code descriptors. These new descriptors focus either on medical decision making or on total time. The goal of this effort was to lessen the documentation requirements and to reduce the burden on physicians. CPT leaders clearly stated that the purpose of these revisions was not to change the E/M code values. However, the new codes will ultimately result in significant Medicare payment cuts to neurosurgeons due to the Medicare physician fee schedule’s budget neutrality requirements.

    New E/M Coding System

    Under the new system, CPT code 99201 was eliminated, and changes were made to the remaining codes for new patient visits (CPT codes 99202 to 99205) and established patient visits (CPT codes 99211 to 99215). CMS continues not to recognize or pay for the consultation visit codes (99241-99245), although other third-party payers may still allow reporting of these codes. The new system will enable neurosurgeons to choose the level of E/M service based on medical decision making alone. Under the current system, E/M codes are selected based on the complexity of decision making possible categories: number of diagnoses or options, amount/complexity of data and risks of complications/morbidity/mortality. (Table 1)

    For time-based reporting, total time is measured on the date that the encounter occurs. The service’s time covers both total face-to-face and non-face-to-face time on the day of service—a significant change from the old system. (Table 2)

    Physician and qualified health care provider time includes:

    • A review of tests;
    • Obtaining a history and performing an exam:
    • Counseling and education;
    • Ordering medications;
    • Ordering tests and procedures;
    • Communicating with other providers;
    • Documenting in the electronic medical record; and
    • Reviewing films and test results.

    Changes in Revised E/M Code Values

    Following the approval of the updated E/M codes, a group of 52 specialty societies participated in the AMA/Specialty Society RVS Update Committee (RUC) survey of the new codes. The RUC adopted new values for these E/M codes, and CMS agreed with the RUC-recommended values, which went into effect on Jan. 1, 2021. (Table 3)

    Additional E/M Policies—No Increase in Global Surgery Codes; Unnecessary Add-on Code

    Unfortunately, despite nearly uniform agreement among the medical community, CMS has refused to adjust the E/M portion of the 10- and 90-day global surgery codes to account for the increased values of the stand-alone E/M codes. Thus, the value of neurosurgical procedures will not increase. For the first time since the advent of the Resource-based relative value scale, the federal government plans to pay physicians differently for the same work. Furthermore, CMS has proposed implementing a new add-on code—G2211 (formerly GPC1X)—for complexity inherent to E/M services that will commonly be reported only by specific subspecialties—not including neurosurgery. 

    Neurosurgery Faced Steep Medicare Cuts—Launched Surgical Care Coalition Campaign

    Because E/M services represent about 40% of the entire Medicare physician fee schedule (MPFS), even small changes in the E/M values significantly impact all provider payments. Regrettably by law, any MPFS changes cannot increase or decrease expenditures by more than $20 million. To comply with this budget neutrality requirement, any increases must therefore be offset by corresponding decreases. Originally, CMS estimated that the 2021 policies—which include additional changes to other E/M services—would increase Medicare spending by approximately $10.6 billion, necessitating steep cuts by reducing the Medicare conversion factor from $36.0896 to $32.4085, or a 10.2% percent decrease. The G2211 add-on code alone would have redistributed over $1.5 billion between specialties.

    Due to the changes to the E/M code values, the failure to incorporate these changes into the 10- and 90-day global codes and the adoption of the new G2211 add-on code, CMS estimated that neurosurgeons will see an overall 6% decline in Medicare payments. When extrapolated to all payers, this cut could amount to as much as $45,000 per neurosurgeon. Additional potential cuts to the global surgery codes could result in even steeper reductions in the future.

    Recognizing that cuts of—with significant funding support from the Council of State Neurosurgical Societies (CSNS) and the Section on Disorders of the Spine and Peripheral Nerves—this magnitude may lead to reduced access to care for older Americans, on June 18, the Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS), along with 10 other national surgical associations, founded the Surgical Care Coalition (SCC). The SCC has launched a targeted, multi-faceted advocacy and public relations campaign to prevent these cuts. Through social media, op-eds, news articles, digital advertisements, radio and television interviews and grassroots advocacy, the SCC has reached millions of Americans—including federal policymakers—urging Congress to prevent these Medicare cuts.

    Legislation to Prevent the Cuts Introduced

    As part of this coalition effort, the CNS and AANS are advocating that Congress adopt legislation that:

    • Increases the global surgery code values;
    • Halts implementation of the G2211 add-on code for complex E/M visits; and
    • Prevents any additional cuts resulting from the new E/M payment policies. 

    Following sustained advocacy by organized surgery and others, on Oct. 30, eight bipartisan members of Congress—Reps. Ami Bera, MD, (D-Calif.); Larry Bucshon, MD, (R-Ind.); Brendan Boyle (D-Pa.); George Holding (R-N.C.); Raul Ruiz, MD, (D-Calif.); Phil Roe, MD, (R-Tenn.); Abby Finkenauer (D-Iowa); and Roger Marshall, MD, (R-Kan.)—introduced H.R. 8702, the “Holding Providers Harmless From Medicare Cuts During COVID-19 Act.” On Dec. 10, Sens. John Boozman (R-Ark.), Kevin Cramer (R-N.D.), Cindy Hyde-Smith (R-Miss.), Tom Cotton (R-Ark.) and Susan Collins (R-Maine) introduced the same bill in the Senate. The purpose of the legislation is to hold health care providers harmless from Medicare payment cuts in 2021 and 2022, while the nation continues to contend with the effects of the COVID-19 pandemic. In addition, Sen. Rand Paul, MD, (R-Ky.) introduced S.4932 the “Medicare Reimbursement and Equity Act”, which would require CMS to adjust the E/M portion of the global surgery code proportionate to the stand-alone E/M codes. The CNS and AANS enthusiastically endorsed both bills. 

    These advocacy efforts were successful, and on Dec. 27, 2020, President Donald J. Trump signed the Consolidated Appropriations Act, 2021 (H.R. 133) into law (P.L. 116-260). The legislation mitigates the 10.2% across-the-board reduction due to budget neutrality requirements in two ways: a 3.75 percent increase in the MPFS for 2021 and by suspending code G2211 for three years, through December 2023. Based on an AMA impact table, the combination of these two policies will significantly reduce the budget neutrality adjustment. Overall, neurosurgeons should not experience any Medicare payment cuts (although the specific impact will depend on the mix of services provided) in 2021. In implementing the new law, CMS has adjusted the 2021 MPFS.  Click here for the updated Addendum B, which includes the relative value units for all services. The 2021 conversion factor is now $34.8931 rather than $32.4085, although still shy of the 2020 CF of $36.0896.

    Our work is not done, and to ensure fair reimbursement for neurosurgeons, the CNS and AANS will continue to advocate for increases in the E/M portion of the global surgery codes and for the permanent elimination of the G2211 add-on code.


    More information about the new E/M codes and neurosurgery’s efforts to prevent steep Medicare cuts is available:

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