E/M office and other and other outpatient visit guidelines will be changing as of January 1, 2021. Below are further details regarding these changes: Read Part I and Part II of this blog for more information.

Major E/M revisions for 2021 regarding time of patient encounters include

• Extensive E/M guidelines additions, revisions, and restructuring
• Deletion of code 99201 and revision of codes 99202 – 99215
• Significant components for code selection:
  • Medically appropriate history and/or examination
  • Medical decision making (MDM) or
  • Total time on the date of the encounter

Differences Between Time Guidelines 2020 vs. 2021

E/M time guidelines through December 31, 2020

• Counseling and/or coordination of care dominates (over 50% of face-to-face time) the encounter with the patient and/or family
• ONLY face-to-face time is counted

E/M time guidelines beginning January 1, 2021

• Time can be used for code selection for office and outpatient service regardless of counseling and/or coordination of care provided
• Time may only be used for code selection of the other E/M services when counseling and/or coordination of care dominates the service

Defining and Qualifying Time for Office and Outpatient E/M Services

“Total Time” definition

• Includes physician/other QHP face-to-face AND non-face-to-face time, such as:
  • Preparing to see the patient (i.e., chart review – including test results)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically necessary examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other healthcare professionals (when not reported separately)
  • Documenting in the patient’s chart
  • Independently interpreting results and communicating results to patient/family/caregiver
  • Coordination of care
• Time spent by clinical staff is NOT included
• More than one clinician addressed (that is not separately billable)

Time associated with New Patient Office Visits (Total time on the date of encounter)

Time associated with Established Patient Office Visits (Total time on the date of encounter)

Other services with revised and relocated time guidelines

• Outpatient services (99241-99245, 99324-99328, 99334-99337, 99341-99345, 99347-99350, 99483)
• Hospital observation services (99218-99220, 99224-99226, 99234-99236), hospital inpatient services (99221-99223, 99231-99233), inpatient consultations (99251-99255), nursing facility services (99304-99318)

Differences Between Prolonged Service Guidelines 2020 vs. 2021

Prolonged Services (99342, 99358, 99XXX) through December 31, 2020

• Prolonged services codes with direct patient contact (99354, 99355) and without direct patient contact (99358, 99359)
  • First hour denoted by base code
  • Each additional 30 minutes denoted by add-on code
• Currently, prolonged services of 30 minutes or less beyond the typical time of the E/M service is not reported separately

Prolonged Services (99XXX) beginning January 1, 2021

• Shorter prolonged services code to capture each 15 minutes of critical physician/other QHP work beyond the time captured by the office or other outpatient service E/M code
  • Use only when the office/other outpatient code is selected using time
  • For use ONLY with 99205, 99215
  • Prolonged services of less than 15 minutes is not reported
  • Allows time to be used on the date of encounter for both face-to-face and non-face-to-face time

CPT Revision

Prolonged Service with or without direct patient contact on the date of an office or other outpatient service

• 99XXX – Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)
  • Use 99XXX in conjunction with 99205, 99215
  • Do not report 99XXX in conjunction with 99354, 99355, 99358, 99359, 99415, 994126
  • Do not report 99XXX for any time unit less than 15 minutes

Final Rule – 2021 Medicare reporting rules on prolonged services

• CMS finalized decision to adopt CPT code 99XXX to report all prolonged time spent on the date of the primary office or other outpatient E/M visit (99205/99215)
• Finalized Medicare 2021 reporting instructions that codes 99358, 99359 will no longer be reportable in conjunction with office or other outpatient E/M visits

Resources: AMA E/M Office Visit Changes