Historic changes are coming to evaluation and management (E/M) codes effective January 1, 2021. The requirements of leveling Office or Other Outpatient Services will no longer be based on the three key components (history, examination, and medical decision making (MDM)). Additionally, reporting the services on time is different.
What are the Changes?
Time – Effective with the January 1, 2021 changes, time is one of two ways in which Office or Other Outpatient Services may be reported. Time will be based on the total time spent on the date of the encounter. This is a significant change of how time is reported with other E/M codes and historically with this set of E/M codes. Counseling and/or coordination of care is no longer required and the time threshold is based on total time and not driven by greater than 50% of the visit spent in counseling and/or coordination of care.
The time requirement only applies to CPT® codes 99202-99215.
| CPT® Code | Total time per Calendar Day (in minutes) |
| 99202 | 15-29 |
| 99203 | 30-44 |
| 99204 | 45-49 |
| 99205 | 60-74 |
| 99211 | No time per CPT® but can infer <10 minutes |
| 99212 | 10-19 |
| 99213 | 20-29 |
| 99214 | 30-39 |
| 99215 | 40-54 |
If the total time does not meet the CPT® range of time for a specific E/M then you have two choices (1) move to a lower level E/M or (2) level the E/M based on the medical decision making.
Note, the time is not 100% face-to-face time. Time is based on total time on one calendar day.
Medical Decision Making – The other way in which an E/M for Office or Other Outpatient E/M Services is based on the medical decision making. The MDM is based on a combination of the following three elements:
- Number and Complexity of Problems Addressed
- Amount and/or Complexity of Data to be Reviewed and Analyzed
- Risk of Complications and/or Morbidity or Mortality of Patient Management
Determining an E/M based on the MDM two of the three MDM elements must be must to support the level of service. The level of MDM required for 99211-99205 are:
| CPT® Code | Level of MDMD |
| 99211 | N/A |
| 99202
99212 |
Straightforward |
| 99203
99213 |
Low |
| 99204
99214 |
Moderate |
| 99205
99215 |
High |
The American Medical Association (AMA) has published a MDM table. Within the table there are requirements within each category. Most notable, there are three “categories” under the element of Amount and/or Complexity of Data to be Reviewed and Analyzed. Depending on the level of MDM determines the number or categories that must be met.
There are Defined Terms
Much of the ambiguity around MDM has been removed under the new leveling method. The AMA has well defined definitions of the various terms used within the MDM grid. For example, what is the difference between a problem addressed compared to a minimal problem. The definitions are helpful in understanding what can be counted under the four levels of MDM.
The AMA has published the documentation guidelines of the effective changes which can be found here.
EHR and other Business Impacts
Practices and provider groups need to not only understand the new way in which to level Office Visit E/M codes but must also fully understand the impact to their practice. There are business impacts that need to be addressed now to test and prepare for the changes.
Many EHR systems have an algorithm to help recommend an E/M level. If you are operating on a system such as this it must be changed for CPT® codes 99202-99215. Vendors should be testing their systems to ensure the EHR is ready and configured to the new changes.
There is the potential for patient impact. Historically providers could not use time spent outside the face-to-face portion of the visit. So a patient who may normally be a level three may now have very similar services and be a level four. One of the purposes of the E/M change was to capture the amount of work providers put into an encounter encompassing all the time spent on the encounter. It is recognized there is pre and post work which contributes to the overall time spent on a patient.
Audit your E/M Services
In an effort to be proactive practices should audit their E/M services. In addition to auditing, conducting education of the changes is important. While the E/M requirements for Office and Outpatient E/M Services has changed medical necessity remains.
Medical necessity has not changed. Every E/M service must be medically necessary and the level of service must be medically appropriate. Audits will continue and potentially increase with these historic changes.
