By:  Jennifer Hayes, DNP, FNP, CPC  and Tania Celia PhD, APRN, FNP-C, CNE

The new year, 2021, brings some significant changes to the CPT® codes Evaluation and Management (E/M) codes 99201-99215, which are commonly used by providers in outpatient settings. The descriptors have been updated to reflect new criteria for selection and CPT® code 99201 has been removed due to redundancy in medical decision making (MDM) requirements with code 99202.

The History & Physical Exam (H&P) previously accounted for the determination of E/M levels. The new guidelines state the history and physical should be “medically appropriate”, determined by the provider based on the condition being addressed and the standard of care. The H&P are no longer key factors in determining the level of the CPT® code for levels 99202-99215. Additional changes in determining E/M use the MDM or time elements:

• CPT® codes can be determined by weighing the three components of the medical decision making: the number and complexity of the problems addressed during a visit, the amount of data reviewed or analyzed during a visit, and the risk of complications and morbidity or mortality based on the patient’s condition and management. The new guidelines still allow for addressing multiple conditions (new or ongoing) at the same visit using the components mentioned.

Some additional caveats providers should be familiar with:

• • • • Tests or studies billed separately, including performing or interpreting these tests, cannot be used when determining the level of MDM for the encounter.
      • Tests or studies performed during the visit, not reported separately, but part of the encounter, can be used in determining MDM, but must be clearly documented in the chart. One example might be “I independently interpreted ____ test and this was used to determine the diagnosis of______”.

 

• CPT® codes can be determined by using the total time for the visit provided and includes time spent with patients face to face and also for non-face to face activities done on the same day for management of the patient.
  • • • Time can be used for office or outpatient E/M selection (99212-99205), whether or not the counseling or coordination of care is the primary reason for the visit. Documentation should still include the time spent for the visit and other activities (ex. collaboration with other providers, adding orders, interpreting tests, patient education, etc.)
      • The times are specific to the E/M codes selected. Note: 99211 does not have a time specified and cannot be used for a visit coded based on time.

The American Medical Association has a new chart which will help to guide providers in determining the correct CPT® code: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

 

 

References:

CPT® Evaluation and Management. American Medical Association. https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management Accessed January 23, 2021.

CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356) Code and Guideline Changes.. American Medical Association. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf  Accessed January 20,2021

CPT® E/M Office Revisions Level of Medical Decision Making (MDM).  American Medical Association. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf  Accessed January 20,2021

What’s Changing for E/M Codes 99201-99215 in 2021? American Academy of Professional Coders. https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx#2021CPT® EMGuidelinesOverview Accessed January 20,2021