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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.

Office or Other Outpatient E/M Code

2021 CPT Time Range for Code Selection

New Patient Code Set

99202

15-29 minutes

99203

30-44 minutes

99204

45-59 minutes

99205

60-73 minutes

Established Patient Code Set

99211

N/A - typically referred to as a “nurse’s visit,” the component of time does not apply to this code

99212

10-19 minutes

99213

20-29 minutes

99214

30-39 minutes

99215

40-54 minutes

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

Code

Level of MDM based on 2 of the 3 elements

Elements of MDM

Number and Complexity of Problems Addressed at the Encounter

Amount and/or Complexity of Data to be Reviewed and Analyzed

Risk of Complications and/or Morbidity or Mortality of Patient Management

99211

N/A

N/A

N/A

N/A

99202

99212

Straightforward

Minimal

 

Minimal or None

Minimal risk of morbidity from additional diagnostic testing or treatment

99203

99213

Low

Low

 

Limited

 

Low risk of morbidity from additional diagnostic testing or treatment

99204

99214

Moderate

Moderate

Moderate

 

Moderate risk of morbidity from additional diagnostic testing or treatment

99205

99215

High

High

Extensive

High risk of morbidity from additional diagnostic testing or treatment

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
 

 

 

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