Be Aware of These Changes in 2021 If You Bill Office/Other Outpatient E&M Codes

After decades with minimal changes to the coding and documentation requirements of CPT’s Evaluation and Management (E/M) code sets, clinicians are looking forward to the revisions the AMA has made to the Office or Outpatient visit code set (99201 – 99215) that become effective January 1, 2021.

1.   99201 is deleted.  To report, use 99202.

The 99201 – 99205 code set is reported for E/M services rendered to New Patients in the Office or Other Outpatient settings.  As both 99201 and 99202 represent a service described as straightforward medical decision-making (MDM), CPT has deleted 99201 for 2021 and directs reporting 99202 in its place.  
•    If you currently bill 99201, you will need to make the appropriate updates in your system and/or to your superbill to avoid payment delays for service dates on and after January 1, 2021.  

2.   Choosing the appropriate level of E/M service can now be based on one of the following:
•    Total time performed on the date of the encounter OR
•    The level of Medical Decision-Making (MDM) for the service rendered

So time alone can now be used to select the appropriate code level for the service - why does that matter?  
Since 1992, CPT has provided reference to typical time represented by each code simply to assist in choosing the appropriate level of E/M service.   However, if a provider wanted to choose the E/M level based solely on time, documentation within the medical record had to clearly state that counseling and/or coordination of care dominated the service.
•    Starting January 1, 2021, time may be the sole element in choosing the E/M code level for office or other outpatient services whether or not counseling and/or coordination of care dominates the service.  
•    TIP:  total “time” includes both face to face and non-face to face time spent by the clinician and has been updated as illustrated below.

How do I use MDM to determine my E/M code level if I don’t want to use the component of time?
Basing your E/M level on Medical Decision Making is a bit more involved and requires understanding that the overall complexity of this component is driven by three elements:
•    The number and complexity of problems addressed at the encounter
•    The amount and/or complexity of data to be reviewed and analyzed
•    The risk of complications and/or morbidity or mortality of patient management

3.  The previous documentation requirements for the history and physical examination components – typically viewed as cumbersome by providers - have been eliminated and replaced with the expectation that documentation is simply medically-appropriate for the service. 
•    These two components will no longer be used in E/M code selection once the 2021 codes go into effect.

Getting ready for the change:
•    If you currently bill 99201, make the necessary changes to begin reporting 99202 instead, starting with January 1, 2021 service dates
•    If you plan to take advantage of the ability to begin reporting your Office/Other Outpatient E/M visits based on the component of time, become familiar with the time ranges as listed above
•    If you’d like more information for reporting your E/M levels based on MDM, visit the AMA’s comprehensive document here