Starting January 1, 2021, new reporting guidelines were implemented for Office and Ambulatory Services Evaluation and Management (E&M) and changes made to code descriptors for office and outpatient E/M codes. As a medical coding outsourcing company serving all specialties, we keep track of industry guidelines and medical coding and billing trends to help physicians submit accurate claims, optimize revenue cycle management, and get reimbursed appropriately.

In the updated 2021 Office and Ambulatory Services Evaluation and Management (E&M) Guidelines, selection of codes for office/outpatient E/M services are based on:

  • Medically Appropriate History and/or Examination and Medical Decision Making

OR

  • Total Time on the Day of Encounter.

The selection of E&M levels of service (LOS) according to time is a key aspect of this E/M update. Let’s take a look at the significance of time in physician office E/M coding.

How “Time” was used Before 2021

Beginning CPT 1992, time was included as an explicit factor to assist in selecting the most appropriate level of E/M services.

In 2020, office and outpatient visit codes 99201-99215 used history, exam, MDM, or time for code selection. The 2020 CPT code set provided guidelines on how to use patient history, clinical examination, and medical decision making (MDM) to determine the correct level of E/M codes. It also included guidance on using time to select E/M codes when counseling, coordination of care, or both made up more than 50% of the intra service time. Best practice was for provider to meet and document these specifications and indicate what was discussed or addressed in the counseling or coordination of care.

In 2021, outpatient and prolonged services codes are based on amount of time.

2021 Time Reporting Changes for Office/Outpatient E/M codes

In 2021, except for 99211, 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, and 99215. The instructions for each category have to be studied as time requirements vary for different categories of services.

The 2021 definition of time, which applies when code selection is based on time and not medical decision making (MDM), is as follows:

  • The minimum time, not typical time spent, and</li
  • Represents total time spent by physician/qualified health care professional (QHP) on the date of service

The 2021 time ranges for physician office E/M Codes are as follows:

New Patient Visits

CPT code MDM 2021 Time Range
99202 Straight forward 15-29 min
99203 Low complexity 30-44 min
99204 Moderate complexity 45-59 min
99205 High complexity 60 min

Established Patient Visits

CPT code MDM 2021 Time Range
99212 Straight forward 10-19 min
99213 Low complexity 20-29 min
99214 Moderate complexity 30-39 min
99215 High complexity 40-54 min

Time in the 2021 code descriptors

  • Time is total time on the encounter date and includes both face-to-face and non-face-to-face time spent by the provider. The total time does not include time for activities the clinical staff normally performs.

  • Examples what time covers for the 2021 codes

    • Preparing to see the patient, such as reviewing tests done prior to the visit
    • The provider getting or reviewing a history that was separately obtained
    • Performing a medically appropriate physical examination;
    • Counseling and education of the patient, a family member, and/or a caregiver;
    • Ordering medications, tests, or procedures, including electronic order entry, and other related tasks;
    • Communicating with other healthcare professionals;
    • Documenting information in the health record
    • Independently interpreting results (not separately reported) and communicating results to the patient, family or caregiver
    • Care coordination (not separately reported)
  • Time may be used to select a code level in office or other outpatient services regardless of whether counseling and/or coordination of care dominates the service. For other E/M services coded based on time, the provider has to meet the threshold of counseling and/or coordination of care taking up more than 50% of the visit.
  • A shared or split visit is when a physician and one or more other qualified healthcare professionals perform the face-to-face and non-face-to-face work for the E/M visit. When coding shared visits based on time, the time spent by the physician and other qualified healthcare professionals should be added to get a total time.
  • Do not include the following when counting time:

    • Time spent on a calendar day other than day the patient was seen’
    • Services that are separately reportable (e.g., chronic care management and transitional care management)
    • Clinical staff time (activities performed by medical assistants, licensed practical nurses, registered nurses

Outsourcing medical billing and coding is a widely accepted strategy to avoid errors that can lead to audits, and payment delays and denials. For medical coding service providers to ensure accurate reporting of E/M services, providers should know the requirements of time-based billing and importantly, ensure documentation that correctly reflects the services provided, total time spent, and medical necessity.