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2021 E/M coding and documentation rules

2021 E/M coding and documentation rules

New rules for reporting outpatient office evaluation and management (E/M) services took effect Jan. 1.  The coding and documentation revisions, adopted by the American Medical Association’s CPT Editorial Panel and approved by the Centers for Medicare and Medicaid Services (CMS) substantially simplify code selection and documentation.

With the exception of 99201, which was deleted, the E/M outpatient visit code numbers remain as follows:

  • 99202-99205: New Patient Office Visits
  • 99211-99215: Established Patient Office Visits
A man with hands on hips looking at chalk drawings of question marks and bags of money

Code selection Medical Decision Making (MDM) or Time

  • Medical decision making (MDM)
  • Time

Although you should still perform a medically appropriate history and/or physical exam, it/they do not determine the level of service.

Coding based on MDM

The four levels of MDM remain the same: straightforward, low, medium, and high. The  three core elements have remained essentially the same and they are:

Number and complexity of problem(s)

  • A problem is the disease, condition, illness, symptom, or other matter addressed at the encounter with or without a diagnosis being established.
  • Multiple new or established conditions may be addressed at the same encounter and may affect medical decision making.
  • Each symptom is not necessarily a problem. Symptoms may cluster around a specific diagnosis or conditions.
  • The final diagnosis for a condition does not, in itself, determine the complexity or risk.
  • Multiple problems of lower severity may, in the aggregate, create a higher risk due to interaction.

Amount and/or complexity of data to be reviewed and analyzed. Data includes:

  • Tests, documents, orders, or independent historians
  • Independent interpretation of tests
  • Discussion of management or test interpretation with external physician or health care professional.

Risk of complications and/or morbidity or mortality of patient management decisions made at visit:

  • Includes possible management decisions selected and those not selected.
  • An example of moderate risk might include prescription drug management or a diagnosis or treatment significantly limited by social determinants of health.
  • An example of high risk might include drug therapy requiring intensive monitoring for toxicity.

To qualify for a level of MDM, two of the three elements for that level of decision making must be met. The College’s matrix on MDM provides more detail on how to determine the level of MDM and code selection.

 

Documentation Tip:

When coding based on MDM, physician notes should address the elements on which the MDM determination is based. Note that while you should document any history and/or physical exam performed, this is no longer a basis for code selection. There is no need to review a certain number of systems, or check boxes.

Coding based on time

The biggest change in E/M coding and documentation is that code selection for outpatient office visits can now be based entirely on time spent on the day of the encounter even if counselling and coordination of care do not dominate the encounter. Clinical staff time does not count. Time includes:

  • All time spent by the physician or qualified health professional (QHP) for the patient on the date of the encounter including:

♦ Preparing to see the patient (e.g., review of tests).

♦ Obtaining and/or reviewing separately obtained history.

♦ Performing a medically appropriate examination and/or evaluation.

♦ Counseling and educating patient/family/caregiver.

♦ Ordering medications, tests, or procedures.

♦ Referring and communicating with other health care professionals (if not separately reported).

♦ Documenting clinical information in the patient’s health record.

♦ Independently interpreting results (not separately reported) and  communicating to patient/family/caregiver.

♦ Care coordination (not separately reported).

  • Time is defined in increments.
  • If time exceeds level 5, the add-on prolonged service code can be used.

 

CodeMinutes
New patient office visits
9920215 – 29 minutes
9920330 – 44 minutes
9920445 – 59 minutes
9920560 – 74 minutes
Established patient office visits
9921210 – 19 minutes
9921320 – 29 minutes
9921430 – 39 minutes
9921540 – 54 minutes

Time for determining visit level

Note: For CPT Code 99211, which describes visits that do not require the presence of a physician, time is not used.

Documentation tips:

  • Complete charting and follow-up on the day of the encounter. Only time spent on the day of the encounter can be counted.
  • On the day of the visit, keep track of and document time spent on getting ready for the patient encounter and follow-up work afterwards, such as care coordination.
  • Only provider time counts – not nurse or medical assistant time. But provider time spent reviewing nurse, medical assistant or scribe documentation does count.

Coding tips:

  • To determine whether to code based on MDM or time, compare visit level based on time with level based on MDM and use the highest level that can be documented using either method.
  •  You may find new and/or complex patient visits are best coded based on time, especially patients that require a fair amount of counseling, care coordination, chart reviews and/or reviewing test results.
  • Many follow-up visits may be best coded based on medical decision making, since they may still involve medical complexity and risk but may not require a great deal of time.

When to Use the Prolonged Service Codes

 There are some important changes in coding for prolonged services. First, the prolonged service code may only be used when coding based on time and only with the level 5 visit codes (99205, 99215). Second, the new codes describe shorter time increments of 15 minutes.

CPT Code 99417 should be used when billing payers other than Medicare. This code, which should only be billed with 99205 or 99215, describes an additional 15 minutes beyond the minimum time of the office visit code. It can be billed in multiple units for each additional 15 minutes of time. Additional time less than 15 minutes should not be reported.

HCPCS Code G2212 was created by CMS and is specific to Medicare. It should be reported for each additional 15 minutes of prolonged service beyond the maximum time for CPT Codes 99205 or 99215. See tables below:

 

Total TimeCode
New patient – Non-Medicare
75 – 89 minutes99205, 99417
90 – 104 minutes99205, 99417 x 2
105 – 119 minutes99205, 99417 x 3
New patient – Medicare
89 – 103 minutes99205, G2212
104 – 118 minutes99205, G2212 x 2
119 – 133 minutes99205, G2212 x 3

 

Total TimeCode
Established patient – Non-Medicare
55 – 69 minutes99215, 99417
70 – 84 minutes99215, 99417 x 2
85 – 99 minutes99215, 99417 x 3
Established patient – Medicare
69 – 83 minutes99215, G2212
84 – 98 minutes99215, G2212 x 2
99 – 113 minutes99215, G2212 x 3

Additional resources:

Webinar: New Outpatient E/M Coding Rules for 2021

ACAAI Coding Toolkit

College Matrix on MDM

The College’s Advocacy Council will continue to provide information on the new codes and coding for 2021 – we have you covered.

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