Healthcare professionals across a wide range of specialties commonly report E/M codes on insurance claims to request reimbursement for services.
The lengthy process required for accurate E/M coding and documentation has caused a lot of confusion and frustration for medical coders and providers over the years. That is one reason why the American Medical Association (AMA), which holds copyright in CPT®, and the Centers for Medicare & Medicaid Services (CMS) are planning major revisions to office and outpatient E/M codes 99201-99215 in 2021.
To understand what’s coming for E/M coding, you need to know the basics of how E/M coding works now.
AMA’s current CPT® code set includes guidelines on using patient history, clinical examination, and medical decision-making (MDM) to determine the correct level of E/M codes. The guidelines also offer information on how to use time to select E/M codes when counseling, coordination of care, or both make up more than 50% of the intraservice time.
Not all E/M codes use history, exam, MDM, or time for code selection, but office and outpatient visit codes 99201-99215 are among those that do. For example, note the references to history, examination, and MDM, as well as the typical time spent, in these 2020 CPT® code descriptors for level 3 E/M codes 99203 and 99213 (bold added for emphasis):
|99203||Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.|
|99213||Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.|
As an alternative to Medicare’s plans, the AMA developed new guidelines and code descriptors for office and outpatient E/M codes. The effective date is Jan. 1, 2021, but because this update will have such a large impact on healthcare providers, the AMA has already posted the revised 2021 office and outpatient E/M guidelines and code descriptors for review. Let’s look at the changes coming, starting with the new patient codes and descriptors.
99201: The 2021 CPT® code set will not include new patient level 1 code 99201. As you’ll see below, the revised code descriptors for the remaining office and outpatient E/M codes use MDM or time to dictate code selection. Code 99201 requires straightforward MDM, the same as 99202, and having two codes requiring the same level of MDM would be redundant.
99202-99205: In 2021, new patient codes 99202-99205 will no longer require the 3 key components or reference typical face-to-face time. Instead, each service includes “a medically appropriate history and/or examination,” and code selection will be based on the MDM level or total time spent on that date.
Compare the 2020 descriptor for 99203 posted earlier in this article to the 2021 code descriptor below:
|99203||Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.|
The descriptors for 2021 codes 99202-99205 all follow the same structure as the 99203 example above. Table 1 shows the requirements for the new patient E/M codes in 2021.
|99202||Medically appropriate history and/or examination||Straightforward||15-29|
|99203||Medically appropriate history and/or examination||Low||30-44|
|99204||Medically appropriate history and/or examination||Moderate||45-59|
|99205||Medically appropriate history and/or examination||High||60-74|
For services longer than 74 minutes, the AMA plans to create a new prolonged services add-on code, temporarily referred to as +99XXX.
The office and other outpatient E/M codes for established patients will change in line with the revisions to the new patient codes in 2021.
99211: Level 1 established patient E/M code 99211 will still be available, but its code descriptor will not include a time reference in 2021:
|99211||Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. |
99212-99215: Established patient E/M codes 99212-99215 will look a lot like the new patient codes in 2021. For instance, review the revised descriptor for 99213:
|99213||Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.|
Table 2 shows the requirements for the 2021 established patient codes. Note the time required difference between the new patient and established patient codes.
|99212||Medically appropriate history and/or examination||Straightforward||10-19|
|99213||Medically appropriate history and/or examination||Low||20-29|
|99214||Medically appropriate history and/or examination||Moderate||30-39|
|99215||Medically appropriate history and/or examination||High||40-54|
You will be able to use the new prolonged services code +99XXX as an add-on code with 99215.
When reviewing the 2021 Guidelines Common to All E/M Services, pay particular attention to the entries for Time and Services Reported Separately.
Time: The Time section of the 2021 E/M guidelines will include important information about proper use of the revised office and other outpatient codes. Here are the major points from the 2021 guidelines for Time: