NEW E/M OFFICE VISIT GUIDELINES PART I

Erika Stevens, CPC - Senior Professional Physician Coding Specialist Coding, MRA Leave a Comment

It has been almost 30 years since evaluation and management (E/M) office visit documentation and coding has been changed.  These changes take place beginning January 1st, 2021. 

The revised guidelines will improve documentation redundancy and support medical necessity.  In the past, the code selection was based on 3 key elements (history, examination, and medical decision making (MDM)) or time spent face-to-face in counseling or coordination of care.  On January 1, 2021, office and other outpatient services will be based on MDM or total time spent with the patient on the date of encounter. 

There have been several talks of revising the E/M office visit codes in the past years.  In 2018 a work-group was formed by the CPT Editorial Panel Co-Chairs along with several physicians. The panel focused on simplifying the work of the healthcare provider and improve health of the patient.  They also wanted to decrease administrative burden by removing the “scoring system” in the history and examination portion of the office visit documentation.  They thought this new practice would promote coding consistency and decrease the need for audits and unnecessary documentation in the patient’s record.  This new standard can improve “higher-level” activities of MDM.  

E/M Revisions 2021 

  • Extensive E/M guideline additions, revisions, and restructuring 
  • Deletion of code 99201 and revision of codes 99202-99215 
  • Components for the new code selection: 
    • Medically appropriate history and/or examination
    • MDM or 
    • Total time on the date of the encounter

E/M level of service can be based on MDM, with extensive changes in the guidelines to define the elements of MDMand time, that consist of total time spent with the patient on the date of encounter, including non-face-to-face services.  Prolonged services will also be revised. 

Office or Other Outpatient Services 

  • History and examination are not used in code selection, should be documented “medically appropriate” 
  • Code selection is based on MDM or total time spent with patient on the date of the encounter 
    • MDM elements include 
      • Number and complexity of the problems addressed during the encounter 
      • Amount and complexity of data to be reviewed/analyzed
      • Risk of complications and/or morbidity or mortality of patient management 

Other E/M Services (Hospital Observation/Inpatient/Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care, Home Visits) 

  • Code selection is based on key elements (history, examination, MDM) 
  • May use face-to-face time when counseling or coordination of care dominates the visit 
    • MDM elements include 
      • Number of diagnoses or management options 
      • Amount and/or complexity of data to be reviewed 
      • Risk of complications and/or morbidity or mortality 

Office or Other Outpatient Services: New Patient Codes 

99201 – Deleted, use 99202 

99202 – Revised, Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes or total time spent on the date of the encounter. 

99203 – Revised, 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 medical decision making. When using time for code selection, 30-44 minutes or total time spent on the date of the encounter. 

99204 – Revised, Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate medical decision making. When using time for code selection, 45-59 minutes or total time spent on the date of the encounter. 

99205 – Revised, Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high medical decision making. When using time for code selection, 60-74 minutes or total time spent on the date of the encounter. 

Office or Other Outpatient Services: Established Patient 

99211 – Revised, for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified healthcare professional.  Usually, the present problem(s) are minimal. 

99212 – Revised, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.  When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter. 

99213 – Revised, 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 medical decision making.  When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. 

99214 – Revised, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate medical decision making.  When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. 

99215 – Revised, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high medical decision making.  When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter. 

 

Resources: AMA E/M Office Visit Changes 

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