On September 1, the American Medical Association (AMA) released the 2021 Current Procedural Terminology (CPT®) code set. There are 329 editorial changes in the 2021 CPT code set, including 206 new codes, 54 deletions, and 69 revisions. Significantly, the CPT code set that comes into effect on Jan, 1, 2021 simplifies coding for E/M services and includes new codes for COVID-19 testing. Physician billing service providers have experienced coders on board who are ready to help providers get ready to use the revised CPT codes and guidelines. Such expert support is important as the AMA described the 2021 updates “as the first major overhaul in more than 25 years to the codes and guidelines for office and other outpatient evaluation and management (E/M) services”.

E/M Office-visit Changes – Key Points

  • History and physical exam are no longer the only elements for E/M code selection.
  • E/M office visit codes 99201 through 99215 have been modified to allow physicians to choose the appropriate code levels based on: 1) The level of medical decision making (MDM) OR 2) The total time performing the service on the day of the encounter. According to the AMA, this builds on the goal to better recognize the work involved in non-face-to-face services like care coordination.
  • Medical decision-making criteria have been modified to focus on tasks that affect the management of a patient’s condition rather than simply adding up tasks.

Changes to E/M Codes

  • Deleted: CPT code 99201 (new patient, level 1) has been deleted. Code 99202 should be used to report this. CPT code 99211 (established patient, level 1) remains a reportable service.
  • Time: Effective January 1, 2021, the definition of time associated with CPT codes 99202-99215 (office or other outpatient services) has been changed from the typical face-to-face time to total time spent on the day of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter.

    Except for CPT code 99211 (“Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician), time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). Different categories of services use time differently:

    New Patient

    99202 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 of total time is spent on the date of the encounter.
    99203 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 level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
    99204 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 level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
    99205 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 level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.

    Established Patient

    99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.
    99212 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 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 level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
    99214 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 level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
    99215 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 level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

  • Medical Decision-making Elements: The medical decision-making elements associated with codes 99202-99215 comprise three components:
    • The number and complexity of problems addressed
    • Amount and/or complexity of data to be reviewed and analyzed, and
    • Risk of complications and or morbidity or mortality of patient management. In order to select a level of E&M service, two of the three elements must be met or exceeded. A new medical decision-making table further outlines the criteria for the E&M code level selection.
  • New CPT Code for Prolonged Services: Beginning in 2021, there is a new code for reporting prolonged services: 99417. CPT code 99417 (with or without direct patient contact) will replace CPT codes 99354 and 99355. The new prolonged services code can be used:
    • For reporting a prolonged office and outpatient E&M service of 15 minutes beyond the total time of the primary E/M procedure (99205 or 99215)
    • When the E&M service has been selected based on time alone (not medical decision making), and
    • Only after the total time exceeds the minimum for a level 5 service (either 99205 or 99215).

The important changes for this year also include new codes for the documentation of COVID-19 testing services.

“To get the full benefit of the burden relief from the E/M office visit changes, health care organizations need to understand and be ready to use the revised CPT codes and guidelines by Jan. 1, 2021,” AMA President Susan R. Bailey, MD, said while announcing the new CPT code set.

Partnering with a reliable physician billing company is the best way for physicians, practices and staff to stay up to date on coding changes to ensure a smooth transition and avoid disruption in reimbursement.