The American Medical Association (AMA) has published the office and outpatient evaluation and management (E/M) CPT code changes that they intend to make in 2021. Understanding how to properly document and code Evaluation and Management (E/M) patient visits is crucial for family practice physicians to optimize medical billing and maximize payment. Partnering with an experienced family practice medical billing company helps many providers achieve these goals and avoid the risk of payer audits.

Medicare announced documentation-related changes for office/outpatient E/M visits (CPT codes 99201 through 99215) in its proposed 2019 physician fee schedule (PFS). Announced by the AMA CPT Editorial Panel in its February 2019 meeting, the new CPT E/M modifications impact only Office or Other Outpatient Services (99201-99205 and 99211-99215) codes. Unless the AMA makes further modifications, the following office and outpatient E/M coding changes will take effect January 1, 2021:

  • Deletion of level outpatient visit CPT code 99201: Code 99201 Office or other outpatient visit for the evaluation and management of a new patient, will be deleted due to low utilization. Code 99201 requires 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making (MDM). The current guideline is to all 3 components to establish the level of a new office/outpatient encounter, and to use 2 out of the 3 elements to establish the level of an established office/outpatient Time can also be used if counseling and coordinating dominate the encounter.
  • History and exam will not have a role in office/outpatient E&M code selection: Starting Jan. 1, 2021, history and exam elements will no longer be factored into office/outpatient E&M code selection, though they will be necessary to report the office/outpatient E&M service. Instead, the codes will be selected either by total time or by level of medical decision-making.
  • Change in definition of “time”: The definition of time associated with 99202-99215 has been changed from “typical face-to-face time” to “total time spent on the day of the encounter.” Starting 2021, physicians will no longer need to establish how much time was devoted to counseling and coordinating on the day of the encounter. The time values associated with each office/outpatient E&M code will reflect the total time spent on the day of the encounter.
  • Revisions to the MDM elements associated with codes 99202-99215: There will be changes to the wording of the MDM elements:
    • Number of Diagnoses or Management Options” will change to “Number and Complexity of Problems Addressed”
    • “Amount and/or Complexity of Data to be Reviewed” will change to “Amount and/or Complexity of Data to be Reviewed and Analyzed”
    • “Risk of Complications and/or Morbidity or Mortality” will change to “Risk of Complications and/or Morbidity or Mortality of Patient Management
  • Additional E/M documentation changes: An AAPC report listed the AMA’s other E/M proposals as follows:

Guidelines for hospital observation, hospital inpatient, consultations, Emergency Department, nursing facility, domiciliary, rest home, custodial care, and home E&M services will not change. The AMA proposes restructuring E/M guidelines into three sections:

    • Guidelines Common to All E/M Services
    • Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care and Home E/M Services”
    • Guidelines for Office or Other Outpatient E/M Services, to distinguish the new reporting guidelines for the Office or Other Outpatient Services codes 99202-99215
      • Adding new guidelines that are applicable only to Office or Other Outpatient codes (99202-99215); adding a Summary of Guideline Differences table of the differences between the different sets of guidelines
      • Revising existing E/M guidelines to ensure there is no conflicting information between the different sets of guidelines
      • Adding a MDM table applicable to codes 99202-99215
      • Adding guidelines for reporting time when more than one individual performs distinct parts of an E/M service
  • Changes to Prolonged Services: Proposed updates include:
    • Revising codes 99354 and 99355 to exclude reporting of Office and other Outpatient Services codes
    • Revising code 99356 to include observation
    • Adding a new code to report prolonged office or other outpatient E/M services

These updates will have implications for documenting E/M services and assigning codes. Payers, including Medicare, have their own set of guidelines for claim submission.  Physicians need to be knowledgeable about payer guidelines and policies to ensure accurate CPT coding and error-free claim submission. Family practice medical coding and billing services are a good option to prepare for these E/M changes in 2021.