Outpatient evaluation and management codes extensively revised

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Robert M. Zwolak

For the first time since 1992, office/outpatient evaluation and management (E/M) Current Procedural Terminology (CPT) codes have been extensively revised. As of Jan. 1, the lowest level new patient visit code 99201 will be deleted, and the remaining new patient visits 99202–99205, along with the established patient office visits 99211–99215 will be revised to eliminate mandatory history and physical exam elements (H&P).

Only a “medically appropriate history and/or examination” will be required for all office/outpatient E/M codes.

The number of body systems/areas reviewed and examined need only be performed and documented to the extent medically necessary and clinically appropriate, and the levels of H&P documentation will no longer count for, or against, the office code level. This change was based on Medicare efforts to reduce documentation burden. It should be noted, however, that this policy may be different for non-Medicare private payors.

Beginning in 2021, physicians may also choose to use medical decision-making (MDM) or total time for selection of the appropriate new and established patient office visit code level. Time has been redefined for this set of codes from “typical face-to-face time” to the sum of both face-to-face and non-face-to-face services of the physician or qualified health professional (QHP) on the date of the encounter. In addition, time may be used to select a code level for office/outpatient EM services, whether or not counseling and/or coordination of care dominates the service.

Each revised code includes a range of time for use when reporting a code using total time. In addition, for the total time that exceeds the highest level of code 99205 or 99215, a new code (99417) has been established to report each additional 15 minutes of incremental time.

Surgeons may choose to report total time for instances where MDM is straightforward or low, but the encounter required significant time. This could be a situation such as if a language barrier slowed the discussion, or the patient and family had numerous questions.

The original four levels of MDM (straightforward, low, moderate, high) have not changed for 2021. However, since 99201 and 99202 both described “straightforward” MDM, code 99201 will be deleted and reported using 99202 beginning in 2021.

MDM continues to have the same three elements (presenting problem, data reviewed/analyzed, risk). The level of MDM for office/outpatient E/Ms will continue to be based on two out of three elements.

In addition to all of these changes, the guidelines for office/outpatient E/M reporting have been extensively revised, including the addition of definitions for many new terms that have been introduced for 2021.

Details about these changes—“CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202–99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes”—can be found at vsweb.org/E/MChanges2021. Please note that code 99XXX has formally been published as 99417.

Code descriptors and reporting requirements for all other non-office/outpatient E/M codes have not changed for 2021.

This means that the legacy 1995 and 1997 E/M documentation guidelines still apply for all inpatient visits, emergency department visits and all consultation codes.

Robert M. Zwolak, MD, is a member of the SVS Coding and Reimbursement Committee and was recently named the American Medical Association (AMA) alternative representative to the organization’s RVS Update Committee (RUC), and alternative vice chair.

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