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.

Office/Outpatient E/M Coding Before 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.

AMA’s 2021 Office/Outpatient E/M Codes: New Patient

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.

Table 1: 2021 Requirements for E/M Codes 99202-99205

Code	History/Exam	MDM	Total Minutes
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.

AMA’s 2021 Office/Outpatient E/M Codes: Established Patient

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. Typically, 5 minutes are spent performing or supervising these services.

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.

Table 2: 2021 Requirements for E/M Codes 99212-99215

Code	History/Exam	MDM	Total Minutes
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.

2021 CPT^® E/M Guidelines for Time and Separate Services

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:

1. You will be able to use time alone to select the correct code from 99202-99205 and 99212-99215. Note that 99211 is not in that list because no time is listed in that descriptor.
2. Counseling and/or coordination of care will not need to dominate an office or other outpatient E/M service for you to code the service based on time in 2021. But for other E/M services that you code based on time, you will still need to meet the threshold of counseling and/or coordination of care taking up more than 50% of the visit.
3. You will use 99211 if clinical staff members perform the face-to-face visit under the supervision of the physician or other qualified healthcare professional.
4. A shared or split visit is when a physician and one or more other qualified healthcare professionals perform the face-to-face and non-face-to-face work for the E/M visit. When you’re coding these visits based on time, sum the time spent by the physician and other qualified healthcare professionals to get a total time. Any time that the providers spend together to meet with or discuss the patient should be counted only once (like you’re counting the time of one individual).
5. A key shift for the office and other outpatient E/M codes is that the time referenced in the 2021 code descriptors is total time. The 2020 descriptors for these codes use intraservice time.
   • The 2021 Time guidelines explain that for 99202-99205 and 99212-99215, total time on the encounter date includes both face-to-face and non-face-to-face time spent by the provider.
   • The guidelines offer the examples of preparing for the visit (such as reviewing tests); getting or reviewing a history that was separately obtained; performing the exam; counseling and providing education to the patient, family, or caregiver; ordering medicines, tests, or procedures; communicating with other healthcare professionals; documenting information in the medical record; interpreting results and sharing that information with the patient, family, or caregiver; and care coordination.
   • When you start counting time for the 2021 codes, you should not include time spent on services you report separately. For instance, if you report care coordination using a separate CPT^® code, you should not include that in the time for the E/M code.
   • The total time also will not include time for activities the clinical staff normally performs.