CMS and the American Medical Association have announced big changes in E&M coding for 2021. These changes were implemented to help ease the burden of documentation requirements for providers. Currently E&M code selection is on a points-based system consisting of three key components: history, examination and medical decision making. Under the 1995/1997 rules, for each service provided, there is an assigned point value. Simply put, the more points, the higher the level of service. Beginning in 2021, CMS will move from this points-based system to one based primarily on medical necessity. With careful planning, understanding and implementation of the new guidelines, providers can now focus more of their time on actual patient care.
Need help understanding the new E&M Coding Changes in 2021, or want to learn more about our Coding and RCM capabilities? Reach out to our Executive Vice President, Matt Thompson, MHSM, ACMPE.
The changes for 2021 only affect outpatient office visit codes (99201- 99215). There are also specific guidelines on which prolonged service codes can be used and how to use them.
So how does this work? The first noticeable change is the provider will no longer be required to document a specific level of history or examination. The new guidelines state documentation of an appropriate history or exam must be based on the patient’s symptoms and diagnoses.
Also in 2021, providers will have the ability to select the level of service based on time spent during the visit. Providers often spend longer time with some patients for relatively minor complaints. There are a myriad of reasons why this happens—extra time to review medical records, taking a history from another source, etc. The 2021 guidelines allow the provider to select a higher E&M code based on time alone, even if the medical decision making is straightforward or low in complexity.
Medical decision making has always played a key role in the selection of the level of service. This will become the key element for code selection in 2021.
Here is one example of a change to a commonly used code — 99214.
E&M 99214 Code Description for 2020:
99214 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
E&M 99214 Code Description for 2021:
99214 – Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes is the amount of total time spent on the date of the encounter.
The following link provides the AMA’s more thorough explanation of the Evaluation and Management changes for 2021: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
AMA CPT® provided the CPT® Evaluation and Management (E/M) Office or Other Outpatient, Prolonged Services Code and Guideline Changes and E/M Office Revisions Level of Medical Decision Making (MDM) table that is included in the 2021 CPT® book. These instructions standardize the code selection for both payers and providers. This gives clear specific guidelines and clear definitions for the 2021 changes and elements listed in the medical decision-making table for time, services that are reported separately and the number and complexity of problems addressed during each encounter.
- ^ Management Resource Group (MRG), “Office Visit Coding Changes for 2021,” Retrieved from: https://www.mrgllc.net/office-visit-coding-changes-for-2021/.