E/M: Be Ready for AMA’s Big 2021 Changes to Office/Outpatient Coding

By: Deborah Marsh

The evaluation and management section of CPT® will see updates to both codes and guidelines. The AMA has released a sneak peek at the E/M updates you can expect in your 2021 CPT® lookup resource. Take advantage of these early-release details to prepare for how the official CPT® codes will compare to Medicare’s 2021 plans … Continue reading E/M: Be Ready for AMA’s Big 2021 Changes to Office/Outpatient Coding

The evaluation and management section of CPT® will see updates to both codes and guidelines.

The AMA has released a sneak peek at the E/M updates you can expect in your 2021 CPT® lookup resource. Take advantage of these early-release details to prepare for how the official CPT® codes will compare to Medicare’s 2021 plans to shake up E/M coding.

Usually, the AMA releases only a CPT® Editorial Summary of Panel Actions from each meeting, providing hints, but few details, about what to expect in CPT® code set updates. But for 2021 changes to E/M, you’ll have more information to work with so you can get ready for these major updates to office and outpatient visit codes. Get started here by learning the major points from AMA’s document on CPT® E/M code and guideline changes.

Recognize the Trends for 99201-99215 Codes and Descriptors

The first big AMA change to E/M codes is that CPT® 2021 will delete 99201, the lowest level new-patient office/outpatient visit E/M code.

The remaining E/M office/outpatient code descriptors (99202-99215) will look a lot different in 2021 compared to now. Expect to see a swap from the current list of key components, which are history, exam, and medical decision making (MDM). Instead, the new code descriptors will require “medically appropriate” history and/or exam, but the level of MDM and the time spent will be the determining factors.

That time element will get an update, too. Instead of referring to typical time, such as “typically, 15 minutes are spent,” the 2021 descriptors will give a range for total time spent on the encounter date. For instance, the descriptor may state that “20-29 minutes of total time is spent.” Low-level code 99211 is the exception, removing the existing five-minute typical time and keeping the note that the code applies when presenting problems are minimal.

Get Familiar with Updated Table for MDM Level

Count on seeing updates to the MDM table in the CPT® E/M guidelines in 2021. You should review the complete Level of Medical Decision Making (MDM) table, including the bullet points, but here are some of the header changes you’ll notice:

    • “Number of Diagnoses or Management Options” will become “Number and Complexity of Problems Addressed”
    • “Amount and/or Complexity of Data to be Reviewed” will become “Amount and/or Complexity of Data to be Reviewed and Analyzed”
    • “Risk of Complications and/or Morbidity or Mortality” will become “Risk of Complications and/or Morbidity or Mortality of Patient Management.”

Go Section by Section to Learn New Guidelines

The CPT® E/M guidelines will have a new structure for 2021, according to the February 2019 CPT® Editorial Summary of Panel Actions. Expect guidelines to divide into the new sections described below.

Guidelines Common to All E/M Services: Some of the more important information you’ll find in this section relates to using time to determine the code. Watch for helpful hints like including both face-to-face and non-face-to-face time in the total time on the encounter date for 99202-99215. The guidelines will also explain shared or split visits.

Guidelines for Office or Other Outpatient E/M Services: This section will help you understand code selection under the new approach to E/M, explaining that you should use either the MDM level or the total time. There are also definitions for MDM elements.

Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care and Home E/M Services: The 2021 changes apply mostly to 99202-99215, which are office/outpatient visit codes. Separating out guidelines by visit-type helps keep it clear which guidelines apply to which codes.

Stay Tuned for News of New Prolonged Services Code

The 2021 changes to E/M codes 99202-99215 will result in revisions to existing prolonged service codes and the addition of a new prolonged service code, too.

For example: Existing prolonged E/M code +99354 will change to specify that you should not report the code in conjunction with 99202-99215.

New code: The AMA will update the code set and the guidelines to incorporate a new add-on code to report prolonged office or other outpatient E/M service(s). The number for the code is not final yet. You’ll use the code for each additional 15 minutes and add it on to top-level codes 99205 and 99215.

Learn More

Tap into expert know-how, stay informed, and get the answers you need to secure optimum reimbursement for your services with your risk-free subscription to E/M Coding Alert. Every monthly issue delivers to-the-point advice, tutorials, and strategies to help you overcome the challenges that threaten your E/M claims.

AMA CPT® 2020 Professional Edition includes the complete 2020 CPT® code set with official descriptors, modifiers, CPT® official coding rules and guidelines, citations from CPT® Changes, CPT® Assistant, and Clinical Examples in Radiology, Appendixes, highlights and symbols for all 2020 coding, guidelines, and text changes, and more.

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