Outpatient E/M Revisions for 2021

The American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) has announced guideline and code descriptor changes for outpatient E/M services to be effective from Jan. 1, 2021. These changes will be applicable only to office or other outpatient E/M codes (99202-99215); all other E/M services will remain unchanged. Till the year 2020, the three key components of an E/M level were history, exam, and Medical Decision Making (MDM). The lengthy process required for the selection of accurate E/M codes and proper documentation has created a lot of confusion and frustration for medical coders and providers. That is one reason why the American Medical Association (AMA), which holds copyright in CPT®, has announced these major revisions to the office and outpatient E/M codes 99201-99215 for the year 2021.

In the year 2021, the history and exam must simply be medically appropriate. They aren’t factored directly into the E/M level, nor must they adhere to a specific type (i.e., problem-focused, expanded problem-focused, detailed or comprehensive). This means streamlined documentation, fewer cumbersome requirements to remember, and potentially more time spent on direct patient care.

For such services, outpatient E/M code selection will be based on medical decision making (MDM) or total time on the date of the encounter. Medically appropriate history and/or examination won’t play any part for code selection. In addition to this major change, the descriptions and guidelines surrounding MDM and time have been redefined.

Due to this revision, physicians and other qualified health professionals (QHP) will be able to code office and outpatient visits solely based on medical decision making (MDM), or on total time. As mentioned earlier, history and exam components will no longer be necessary for E/M code selection.

  • History and physical exam eliminated as elements for code selection.
  • Physicians and qualified health professionals (QHP) has to choose whether their documentation is based on medical decision making (MDM) or total time on the date of service.
  • Modifying medical decision-making criteria which will affect the management of a patient’s condition.

Key Takeaways for Outpatient E/M Revisions

  • In-patient vs Out-patient: These E/M changes only apply to outpatient E/M office visits (CPT codes 99202-99215). For all other outpatient services, including consultations and emergency visits, will continue to use the same key elements for leveling visits. As per new e/m revisions, code 99201 will be deleted due to low utilization.
  • History and Physical Exam: Although history and physical exam are no longer required to level the visit, they are still important components in establishing medical necessity, supporting medical decision making, and providing high-quality care. Documenting the history and physical exam components helps maintain continuity of care and assists other care team members.
  • Total Time: Total time is defined as the total time spent on the day of the encounter. As a physician, your documentation needs to justify the time spent for the visit. Use your documentation to justify the medical necessity for the level of service that is being billed. Do not document a time range (even though the CPT code description identifies a time range for each E/M code). Document the actual time spent precisely.
  • Documenting Assessment and Plan: Assessment and plan should always be documented for each visit. The A/P may provide additional information that will allow your visit to be leveled if the time statement does not have enough information. If the A/P is not documented and the total time is ambiguous or missing, the visit may be unbillable. If you document both MDM and total time, you can level the visit based on whichever is more advantageous, but you still must present documentation. Documentation of an A/P is also important in establishing medical necessity and maintaining continuity of care.

Component(s) for Code Selection

Outpatient Services

Other E/M Services

History and Examination As medically appropriate. Not used in code selection Use Key Components (History, Examination, MDM)
Medical Decision Making (MDM) May use MDM or total time on the date of the encounter Use Key Component (History, Examination, MDM)
Time May use MDM or total time on the date of the encounter May use face-to-face or time at the bedside and on the patient’s floor or unit when counseling and/or coordination of care dominates.
MDM Elements
  • Number and complexity of problems addressed at the encounter
  • The amount and/or complexity of data to be reviewed and analyzed
  • Risk of complications and/or morbidity or mortality of patient management
  • Number of diagnoses or management options
  • The amount and/or complexity of data to be reviewed
  • Risk of complications and/or morbidity or mortality

The new guidelines may appear simpler and more flexible but be sure to prepare for this transition. It’s important to remember the new guidelines only apply to the office or other outpatient codes (99202 to 99215). For other services, such as inpatient, observation, emergency department, and all other E/M services, the 1995 and 1997 guidelines will remain unchanged.

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