The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) have revised the Evaluation and Management (E/M) coding guidelines used for coding the "Office or Other Outpatient Services" category extensively. These changes are the result of the CPT/RVU Workgroup's commitment to simplifying the work of health care providers and improving patient health.
In 2021, the American Medical Association (AMA), which owns CPT, and the Centers for Medicare & Medicaid Services (CMS) implemented significant revisions to office and outpatient E/M codes 99201-99215. The changes aimed to simplify the coding and documentation requirements for these commonly reported codes.
Changes for Management (E/M) Office or Other Outpatient (99202-99215)
Key changes to remember
- History and examination will no longer have a significant role in office/outpatient E/M code selection: Although they are necessary factors to report an E/M visit, starting Jan. 1, 2021, the history and examination elements will no longer be key factors in the office/outpatient E/M code selection.
- Deletion of CPT code 99201: Due to low utilization of the level 1 code for office or other outpatient visit for the evaluation and management of a new patient, CPT code 99201 will be deleted in 2021.
- Change in definition of time: The definition of time associated with E/M levels 99202–99215 changed from “typical face-to-face time” to “total time spent on the day of the encounter.” Providers no longer need to establish how much time was devoted to counseling and coordinating on the day of the encounter. The time values associated with each of the revised office/outpatient E/M codes reflects the total time spent on the day of the encounter.
- Revisions to the MDM elements for codes 99202–99215: There will be changes to the wording of the MDM elements:
- “Number of Diagnoses or Management Options” will change to “Number and Complexity of Problems Addressed”
- “Amount and/or Complexity of Data to be Reviewed” will change to “Amount and/or Complexity of Data to be Reviewed and Analyzed”
- “Risk of Complications and/or Morbidity or Mortality” will change to “Risk of Complications and/or Morbidity or Mortality of Patient Management”
Coding Based on Time
When using time as the basis for code selection, the appropriate time must be documented in the medical record. The total time for shared or split visits is calculated by adding the individual time of both providers. If the patient is seen by both providers at the same time, only one individual's time should be counted. Time requirements are:
99202 15-29 min
99203 30-44 min
99204 45-59 min
+99417* minutes and beyond for each 15 minutes of time.
99211 No time reference
99212 10-19 minutes
99213 20-29 minutes
99214 30-39 minutes
99215 40-54 minutes
+99417* 55 minutes and beyond for each 15 minutes of time.
Coding Based on Medical Decision Making
The E/M guidelines for 2021 include several definitions for terms found in the new MDM, such as an acute, complicated injury, which is defined as:
An injury that necessitates treatment that includes evaluation of body systems that are not directly related to the injured organ, the injury is extensive, the treatment options are numerous, and/or the risk of morbidity is high. A head injury with a brief loss of consciousness is one example.
It is critical to understand all of the terms before deciding on a level of service. Overall, MDM is still based on meeting the level of service requirements for two of the three elements of:
- Number and complexity of problems addressed at the encounter
- Amount and/or complexity of data to be reviewed and analyzed
- Risk of complications and/or morbidity or mortality of patient management
Each element, however, is defined differently. The level of MDM required increases as the level of service increases for codes 99202 to 99205 for new patients and 99211 to 99215 for established patients. This is unchanged from current MDM levels, except that code 99201 has been removed because it is no longer required in the future framework. The concept of MDM level does not apply to code 99211.
It is critical to remember that the guidelines only apply to office or other outpatient codes (99202 to 99215).