It is an overview of the 2021 E&M Coding Changes by the American Medical Association (AMA) in outpatient and office-based visits.
From January 1, 2021, there will be major changes to the office and outpatient Evaluation and Management (E&M) services (CPT Code 99202 and 99215) for both new and established patients. Practices, physicians, and staff must know about these 2021 E&M Changes to avoid revenue fall any continued reimbursements. All EMR/EHR vendors are also required to update their software to accommodate new E&Mchanges.
2021 E&M Changes Reason
The main reason behind 2021 E&M Changes is to reduce the administrative workload of coding documentation on the healthcare providers by:
- Reducing the audit requirements by expanding key definitions and guidelines
- Taking away the unnecessary documentation in the medical record that is not required for patient care
- Recommending resource-based payment for E&M codes
Billing and Coding Changes
New patient level-1 CPT code (99201) is deleted, decreasing the number of levels for new patient office/outpatient E/M visits 4. However, for established patients, the coding level remains 5.
- Patient history and physical examination are not any more the deciding points for selecting the level of care. However, patient medical history and physical exam must still be documented where these are clinically required.
- The Service level can be determined based on medical decision making or on the criteria of time spent on service.
- Reduce the documentation insufficiency related denials across all insurances
Medical decision making is decided on the on the following 3 distinct elements that a medical service provider should consider:
- Number and complexity of problems addressed
- The amount and/or complexity of data to be reviewed and analyzed
- Risk of complications and/or morbidity or mortality of patient management
Prolonged Services Code
Please use CPT Code 99417 for prolonged total time in the Office or Other Outpatient Services. This CPT code is used when the service is selected based on time alone as the factor, applicable only when the total time of the highest-level service (CPT Code 99205 or 99215) has exceeded. However, to report bill CPT Code 99417, at least 15 minutes of additional time must have been spent. The medical billing staff should not use CPT codes 99354 and 99355 for prolonged services with office or outpatient visits.