2021 Changes for Office and Other Outpatient E/M Services

Contents

Overview –

The American Medical Association (AMA) in conjunction with the Centers for Medicare & Medicaid Services (CMS), have announced changes for office and other outpatient E/M services that will go into effect on Jan. 1, 2021. The changes only pertain to office or other outpatient E/M service codes (99202-99215); all other E/M services will remain unchanged.

The new E/M guidelines are specific to office and other outpatient CPT^®1 codes 99202-99215
The CPT code 99201 will be deleted
Providers will now select the appropriate E/M code based on either the level of medical decision making (MDM) or total time
History and examination will no longer be significant in determining the level of service, only when medically appropriate
Total time is defined as “total time spent on the day of the encounter”
Revisions to the MDM elements for codes 99202–99215:
- “Number of Diagnoses or Management Options” will change to “Number and Complexity of Problems Addressed”
- “Amount and/or Complexity of Data to be Reviewed” will change to “Amount and/or Complexity of Data to be Reviewed and Analyzed”
- “Risk of Complications and/or Morbidity or Mortality” will change to “Risk of Complications and/or Morbidity or Mortality of Patient Management”
A new prolonged services code (99xxx) has been created to describe a prolonged office and outpatient E/M service of 15 minutes beyond the total time of the primary E/M code for CPT codes 99205 or 99215.

Selecting an E/M Code Based on Medical Decision Making

Starting on January 1st, 2021, providers may select the level of office and outpatient E/M service based on either Medical Decision Making (MDM) or Time.

Medical decision making is currently part of the Evaluation and Management selection components. However, changes have been made to the elements of medical decision making and the criteria for selection.

Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Medical decision making in the office and other outpatient services code set is defined by three elements:

Problem: The number and complexity of problem(s) that are addressed during the encounter.
Data: Amount and/or complexity of data to be reviewed and analyzed.
Risk: Risk of complications and or morbidity or mortality of patient management.

In order to select a level of an E/M service, two of the three elements of medical decision making must be met or exceeded.

Definitions of MDM Elements

The new guidelines provide updated definitions for the elements of medical decision making for office or other outpatient services.

Problem

A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.

Problem addressed

A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.

Minimal problem

A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211).

Self-limited or minor problem

A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.

Stable, chronic illness

A problem with an expected duration of at least a year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). ‘Stable’ for the purposes of categorizing medical decision making is defined by the specific treatment goals for an individual patient. A patient that is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant. Examples may include well-controlled hypertension, non-insulin-dependent diabetes, cataract, or benign prostatic hyperplasia.

Acute, uncomplicated illness or injury

A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor, but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain.

Chronic illness with exacerbation, progression, or side effects of treatment

A chronic illness that is acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care.

Undiagnosed new problem with uncertain prognosis

A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.

Acute illness with systemic symptoms

An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms such as fever, body aches or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness or to prevent complications, see the definitions for ‘self-limited or minor’ or ‘acute, uncomplicated.’ Systemic symptoms may not be general, but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis.

Acute, complicated injury

An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity. An example may be a head injury with brief loss of consciousness.

Chronic illness with severe exacerbation, progression, or side effects of treatment

The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care.

Acute or chronic illness or injury that poses a threat to life or bodily function

An acute illness with systemic symptoms, or an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Examples may include 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, or an abrupt change in neurologic status.

Test

Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique tests is defined in accordance with the CPT code set.

External

External records, communications and/or test results are from an external physician, other qualified health care professional, facility or healthcare organization.

External physician or other qualified healthcare professional

An external physician or other qualified healthcare professional is an individual who is not in the same group practice or is a different specialty or subspecialty. It includes licensed professionals that are practicing independently. It may also be a facility or organizational provider such as a hospital, nursing facility, or home health care agency.

Independent historian(s)

An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian(s) is needed, the independent historian(s) requirement is met.

Independent Interpretation

The interpretation of a test for which there is a CPT code and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional is reporting the service or has previously reported the service for the patient. A form of interpretation should be documented, but need not conform to the usual standards of a complete report for the test.

Appropriate source

For the purpose of the Discussion of Management data element, an appropriate source includes professionals who are not health care professionals, but may be involved in the management of the patient (eg, lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers.

Risk

The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as ‘high’, ‘medium’, ‘low’, or ‘minimal’ risk and do not require quantification for these definitions, (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization.

Morbidity

A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.

Social determinants of health

Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.

Drug therapy requiring intensive monitoring for toxicity

A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent, but may be patient specific in some cases. Intensive monitoring may be long-term or short term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for a cytopenia in the use of an antineoplastic agent between dose cycles or the short term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis. Examples of monitoring that does not qualify include monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold.

How To: Select an E/M Code based on the 2021 medical decision making guidelines.

Step 1: Problem

Select the appropriate number and complexity of problems addressed during the encounter.

Step 2: Data

Select the amount and/or complexity of data to be reviewed and analyzed.

Step 3: Risk

Select the risk of complications and/or morbidity or mortality of patient management.

Step 4:

Now put the selections together to determine the appropriate E/M code level as shown in the example below:

The appropriate code level to select would be level 4 – Moderate (99204 or 99214), as two of the three elements of medical decision making was met within the level category.

Selecting an E/M Code Based on Total Time

Starting in 2021, for office or other outpatient services (CPT^® codes 99202-99205, 99212- 99215), the time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).

Note: When determining the level of E/M code based on the total time, the appropriate time should be documented in the medical record when it is used as the basis for code selection.

For office or other outpatient services (CPT codes 99202-99205, 99212- 99215), time may be used to select a code level whether or not counseling and/or coordination of care dominates the service. However, time may only be used for selecting the level of the other E/M services when counseling and/or coordination of care dominates the service.

2021 E/M Code Time Intervals

The total time intervals corresponding to New Patient E/M CPTcodes 99202-99205 are as follows:

The total time intervals corresponding to Established Patient E/M codes 99211-99215 are as follows:

For example, in order to report 99215, 40 to 54 minutes of total time must be spent on the date of the encounter by the physician or qualified health care professional.

Acceptable Time-Based Activities

Physician/other qualified health care professional time includes the following activities, when performed:

Preparing to see the patient (eg, review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported) and communicating results to the patient, family, or caregiver
Care coordination (not separately reported)

Split and/or Shared Visits

In circumstances where the physician and qualified healthcare professional each perform the face-to-face and non-face to face work for a visit, the time spent by each is summed for the total time.

For example, a physician spends five minutes of time with an established patient and a physician assistant spends 25 minutes on the date of the encounter. The total time of the visit would be 30 minutes (5 + 25); and therefore, CPT code 99214 (30 to 39 minutes) would be selected per the new guidelines.

Prolonged Service With or Without Direct Patient Contact on the
Date of an Office or Other Outpatient Service

Code 99XXX is used to report prolonged total time (ie, combined time with and without direct patient contact) provided by the physician or other qualified health care professional on the date of office or other outpatient services (ie, 99205, 99215).

Code 99XXX is only used when the office or other outpatient service has been selected using time alone as the basis and only after the total time of the highest-level service (ie, 99205 or 99215) has been exceeded. To report a unit of 99XXX, 15 minutes of additional time must have been attained. Do not report 99XXX for any additional time increment of less than 15 minutes.

Time spent performing separately reported services other than the E/M service is not counted toward the time to report 99205, 99215 and prolonged services time.

Do not report 99XXX in conjunction with 99354, 99355, 99358, 99359, 99415, 99416