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This guest post on the 2021 E/M Changes and Guidelines is from the coding team at BilledRight. BilledRight is a Revenue Cycle Management company and a proud sponsor of this site.
Purpose
Aside from all the major events that occurred in 2020, a major overhaul was the release of the changes in codes and guidelines for Evaluation and Management (E/M) services, which was implemented starting January 1, 2021. The ultimate goal from these foundational changes is to relieve physicians from unnecessary documentation burdens and help them focus better on patient care. This guide will summarize the E/M changes and describe the implications on clinical documentation.
Below are the two key criteria that determine the level of E/M (Office and/or Outpatient visits):
- Time
- MDM (Medical Decision Making)
Guidelines for Time and Separate Services
The revised office and other outpatient codes and key points are:
- Time alone can be used to select the appropriate code from 99202 – 99205 and 99212 – 99215.
- Counselling and/or Coordination of care will not need to dominate an office or other outpatient E/M services
- For other E/M services, still need to meet the threshold of Counselling and/or Coordination of caretaking up more than 50% of the visit
- Shared or Split visit – When a physician, one or more other Qualified Health Professionals (QHP) perform the face to face and non-face to face work for the E/M visit and coding based on time, the sum of the time spent by the physician and other QHP and any time that the providers spent together to meet with or discuss with the patient should be counted only once.
- A key change is the CPT code descriptor specifying the total time,
- Total time on the encounter date includes both “Face-to-face” and “Non-face-to-face” time spent by the provider
- When counting time, do not include the time spent on services that are reported separately,
- Coordination of care is reported using a separate code, do not include time for the E/M code
- Total time will not include time for activities the clinical staff normally performs.
- Examples of what can be included in total time spent are
- preparing for the visit (reviewing the tests),
- Getting or reviewing a history that was separately obtained
- Performing the exam
- Counselling and providing education to the patient, family, or caregiver
- Ordering medicines, tests, or procedures
- Communicating with other healthcare professionals
- Documenting information in the medical record
- Interpreting results and sharing the information with the patient, family, or caregiver
- Coordination of care
- CPT 99211
- CPT 99211 can be used if clinical staff members perform the face-to-face visit under the supervision of the physician or other QHP (Qualified Healthcare professional)
- CPT 99211 is not in that list as no time is listed in the code descriptor.
- Services Reported Separately:
- The 2020 E/M guidelines include information about services reported separately.
- The 2021 guidelines will give this information in its heading and add some clarifications.
- In particular, watch for this line: “If a test/study is independently interpreted to manage the patient as part of the E/M service, but is not separately reported, it is part of medical decision making.”
Guidelines for History and Exam
Office and other outpatient E/M services include a “Medically appropriate History and/or Physical Examination” when performed
- Medically appropriate meaning – the physician or other QHP reporting the E/M determines the nature and extent of any history or exam for a particular service.
- The code selection does not depend on the level of history or exam
- Guidelines specify that the “Care Team” may collect information and the patient (or Caregiver) may provide information (such as by portal or questionnaire).
- The Reporting Provider must then review that information
Guidelines for Medical Decision Making (MDM)
MDM includes establishing diagnoses, assessing the status of a condition and/or selecting a management option.
Three elements define MDM for Office/Outpatient visits in 2021:
- Number and complexity of the problem or problems the provider addresses during the E/M encounter
- The amount and/or complexity of data to be reviewed and analysed
- Tests, documents, orders, or independent historians
- Independent test interpretation
- Discussion of management or test interpretation with external providers or appropriate sources
- External providers – non-healthcare, non-family sources involved in patient management (like a parole officer or case manager)
- Risk of complications, morbidity, and/or mortality of patient management decisions made at the visit.
- MDM Table – has 3 main columns with the final column divided into 3 additional columns,
- Code
- Level of MDM (Based on 2 out of 3 elements of MDM)
- Elements of Medical Decision Making
- Number and Complexity of problems Addressed
- Amount and/or Complexity of Data to be reviewed and Analysed
- Risk of Complications and/or Morbidity or Mortality of patient Management
One important point in the 2021 guidelines is, the final diagnosis isn’t the only factor when you determine the complexity or risk.
A patient may have several lower severity problems that combine to cause higher risk, or the provider may have to perform an extensive evaluation to determine a problem is of lower severity.
2021 Requirements for E/M codes (CPT 99202 – 99205)
2021 Requirements for E/M codes (CPT 99212 – 99215)
2021 MDM Table for E/M: From ama-assn.org:
Example –
- For 99203 and 99213 you will have to meet the requirements for at least one of two categories.
- For codes 99204 and 99214, you’ll have to meet the requirements for one of three categories.
- For the highest-level codes 99205 and 99215, you’ll have to meet the requirements for two of three categories.
- The lower level codes don’t have categories in that column.
Common Terms and Definitions used in MDM
Self-limited or Minor Problem
- A problem that runs a definite and prescribed course, is transient and is not likely to permanently alter health status.
- This term is relevant for Straightforward MDM codes (99202 & 99212)
Risk
- Related to the probability of something happening, but risk and probability are not the same for E/M coding.
- A high probability of a minor adverse effect may be low risk depending on the case. The terms “High”, “Medium”, “Low” and “Minimal” risk are meant to reflect the common meanings used by clinicians.
- For MDM, base risk on the consequences of the addressed problems when they are appropriately treated.
- Risk also comes into play for MDM when deciding whether to begin further testing, treatment, or hospitalization.
External Physician or Other QHP
- Someone who is not in the same group practice or is classified as a different specialty or subspecialty.
- Review of external notes is included in the Office/outpatient E/M codes for levels 3 to 5
- Discussion with an external provider is included in levels 4 & 5
Independent Historian
- Is a family member, witness, or other individuals who provide patient history when the patient can’t provide a complete history or the provider thinks a confirmatory history is needed?
- Assessment requiring an independent historian is included in office/outpatient E/M levels 3 to 5.
Social Determinants of Health (SDOH)
- These are economic and social conditions that influence health
- Persons with potential health hazards related to socioeconomic and psychosocial circumstances.
- Example of moderate risk from additional diagnostic testing or treatment because SDOH like housing insecurity may limit those options
Drug therapy requiring intensive monitoring for toxicity
- Below are some of the examples that qualify as intensive monitoring for toxicity
- The drug can cause serious morbidity or death
- Monitoring assesses adverse effects, not therapeutic efficacy
- The type of monitoring used should be generally accepted kind for that agent although patient-specific monitoring may be appropriate too.
- Long-term or short-term monitoring is ok
- Long-term monitoring occurs at least quarterly
- Labs, imaging, and physiologic tests are possible monitoring methods. History and exam are not.
- Monitoring affects MDM levels when the provider considers monitoring as part of patient management.
An example of drug therapy requiring intensive monitoring for toxicity is testing for Cytopenia (reduction in the number of mature blood cells) between antineoplastic agent dose cycles.
Morbidity
State of illness or functional impairment that is expected to be if substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.
It’s an important term to understand for the acute and chronic illness as defined below
Acute & Chronic Illnesses
The number and complexity, or problems addressed in the column of MDM table:
| Term | Description | Examples |
| Acute, Uncomplicated Illness or injury | The problem is recent and short-term. There is a low risk of morbidity. There is little to no risk of mortality with treatment. Full recovery without functional impairment is expected. The problem may be self-limited or minor, but it is not resolving in line with a definite and prescribed course. | Cystitis Allergic rhinitis Simple sprain |
| Acute Illness with systemic symptoms | The illness causes systemic symptoms, which may be general or single system. There is a high risk of morbidity without treatment. For a minor illness with systemic symptoms like fever or fatigue, consider acute, uncomplicated or self-limited/minor instead. | Pyelonephritis Pneumonitis Colitis |
| Acute, complicated injury | Treatment requires evaluation of body systems that aren’t part of the injured organ, the injury is extensive, there are multiple treatment options, or there is a risk of morbidity with treatment | Head injury with brief loss of consciousness |
| Stable, chronic illness | This type of problem is expected to last at least a year or until the patient’s death. A change in stage or severity does not change whether a condition is chronic. The patient’s treatment goals determine whether the illness is stable. A patient who hasn’t achieved their treatment goal is not stable, even if the condition hasn’t changed and there’s no short-term threat to life or function. The risk of morbidity is significant without treatment. | Well-controlled hypertension Non-insulin dependent diabetes Cataract Benign prostatic hyperplasia NOT stable: Asymptomatic but persistently poorly controlled blood pressure (pressures don’t change), with a treatment goal of better control |
| Chronic illness with exacerbation, progression, or side effects of treatment | The chronic illness is getting worse, is not well controlled, or is progressing “with an intent to control progression.” The condition requires additional care or treatment of the side effects. Hospital level of care is not required. | |
| Chronic illness with severe exacerbation, progression, or side effects of treatment | There is a significant risk of morbidity. The patient may require hospital care. | |
| Acute or chronic illness or injury that poses a threat to life or bodily function | There is a near-term threat to life or bodily function without treatment. An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment may be involved. | Acute myocardial infarction Pulmonary embolus Severe respiratory distress Progressive severe rheumatoid arthritis Psychiatric illness with potential threat to self or others Peritonitis Acute renal failure Abrupt change in neurologic status |
2021 Changes for Prolonged Services
CPT code descriptor for prolonged services code,
+99XXX – Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; every 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)
| New patient | Established Patient |
| 99XXX (75 – 89) | 99XXX (55 – 69) |
| 99XXX (90 – 104) | 99XXX (70 – 84) |
| 99XXX (105+) | 99XXX (85+) |
Below are the key points to be noticed in the descriptor:
- Code +99XXX will apply only if you chose the primary E/M code based on time.
- The new code will include total time with and without direct patient contact on the date of service.
- Remember that 99202 – 99215 also will use total time rather than intra-service time starting in 2021.
- Use +99XXX once for every 15 minutes beyond the primary service time
- The appropriate primary codes will be only 99205 which represents the longest time among the new patient codes and 99215 which represents the longest time among the established patient codes
Guidelines
- +99XXX should not be reported for any period of fewer than 15 minutes.
Example –
- CPT 99205 represents 60-74 minutes in 2021. To report 75-89 minutes, you will report 99205 & +99XXX.
- Once the total time reaches 90-104 minutes, report 99205 & 2 units of +99XXX
For additional resources, The AMA has developed an extensive online resource library that includes a checklist, videos, modules, guidebooks, as well as other tools and resources to help transition to the revised E/M office visit codes and guidelines.
I hope this is useful for all of us as we navigate these new 2021 E/M changes and guidelines.