New guidelines for office and other outpatient E/M services were created to reduce the burden on provider documentation and align code selection with how providers practice. These changes apply to only 99202-99215 codes. When other E/M codes are billed (such as inpatient visits or ED visits) either 1995 or 1997 documentation guidelines are used as applicable.
Providers are not required to document a certain level of history or examination to meet a specific code definition. It will be the providers decision as to what level of history or exam are needed to treat the patient. The code descriptors for 99202-99215 have been revised to include the phrase “medically appropriate history and/or exam”. Determination of the code will be based on either the level of medical decision making (MDM) or time.
Since 99201 and 99202 have the same level of MDM, straightforward, 99201 has been deleted. As an example, 99202 will be defined as “Office or other outpatient visit for the evaluation and management of a new patient which requires a medically appropriate history and/or exam and straightforward medical decision making. When using time for code selection, 15-29 minutes is spent on the date of the encounter.”
A new MDM table appears in the 2021 CPT edition. This table is similar to the table of risk used to determine the level of risk for 1995 and 1997 documentation guidelines. Providers must review this table and utilize it in determining the appropriate code to report for services 99202-99215.
Time for codes 99202-99215 is defined as total time instead of face to face time. Time is defined for these codes as both face-to-face and non-face-to-face time and only includes the provider’s time and not that of ancillary staff. If using time to select one of these codes the time must be documented in the medical record as well as the services performed.
The total time used for code selection includes time spent by the provider on the date of service performing tasks below:
- Preparing to see the patient
- Obtaining a history and performing an exam
- Counseling and educating the patient/family/caregiver
- Ordering medication, tests, or procedures
- Referring and communicating with other healthcare professionals
- Documenting the health record
- Independent interpretation of tests (not separately reported/billed) and communicating results
- Care coordination (not separately reported/billed)
Time spent performing services which are separately reported/billed should not be counted toward the total time for selecting the E/M code. As an example, if an EKG/93000 performed and billed the time the provider spends interpretating the test is not counted toward total time.
Prolonged service codes 99354-99357 may no longer be reported with 99202-99215. When the total time exceeds the highest level of service either 99205 or 99215 use the new prolonged care code 99417. This is defined as;
Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure” for each additional 15 minutes. The 2021 CPT contains an updated table to assist with proper use of this and other prolonged care codes.
Novitas has added a section specific to the 2021 E/M changes which can be accessed under the Evaluation and Management Module. It contains a FAQ page with links to the AMA site for E/M guidelines, the revised AMA MDM table, and other pertinent information.
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00241502
Below is a portion of the FAQ document.
1. Where can the CPT E/M code and guideline changes for 2021 be found?
The CPT E/M code and guideline changes for 2021 can be found in the American Medical Association (AMA) CPT® E/M office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99XXX) code and guideline changes for 2021.
2. Where can the revised medical decision-making table for 2021 be found?
The revised medical decision-making table can be found in the AMA Table 2 – CPT® E/M office revisions level of medical decision making (MDM).
3. There are 22 new definitions in the CPT E/M changes for 2021. Where can the 22 new definitions be found?
The new definitions can be found in the AMA CPT® E/M code and guideline changes for 2021.
