Now that we have all been using the new 2021 evaluation and management guidelines for a couple months now, hopefully the new routine is getting more comfortable. Here are a few reminders of this years’ changes and documentation requirements that were effective as of January 1, 2021.

As you may know, the main code set that changed was the “office and other outpatient visits” code set (99201-99215.) The 99201 code has been eliminated of course, and the criteria to select 99202-99215 has changed and the codes are now selected based on medical decision making (MDM) or time. The American Medical Association has put together a great reference grid to select the level of service based on MDM, which you can find at: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf.

The MDM now consists of the following three categories:

  1. the number and complexity of problems addressed
  2. the amount and complexity of data ordered, reviewed, or analyzed
  3. the risk of complications, morbidity, or mortality.

The grid is similar to the 1995 and 1997 table of risk grids, but there are a few differences, especially in the data column. But there are great notes within the grid to help remind us what the requirements are to meet each category and in turn, each E/M level.

Time may also be used to bill for the 99202-99215 codes; however, the time requirements have changed for this category. Counseling and coordination of care are no longer required to dominate the visit and in fact, the provider’s total time spent on the encounter can now count towards the service, including non-face-to-face time before or after the patients appointment. Non-face-to-face time may include any of the following: preparing to see the patient, reviewing/ordering tests, referring and communicating with other healthcare professionals, and documenting clinical information in the health record. The code descriptions have also changed to include time ranges instead of a minimum time, which is an important distinction especially when considering if prolonged services can be billed. The new prolonged service code for non-Medicare patients is 99417 and can be used along with 99205 and 99215 codes when an additional 15 minutes or more is spent beyond the minimum time stated in the time range for the level 5 office visit codes. Medicare uses HCPCS code G2212 for prolonged services instead which requires an additional 15 minutes or more beyond the maximum time listed for the level 5 office visit codes.

Medical decision making or time can be used to choose the level of service in this category, whatever is most advantageous to the provider based on documentation of course. And even though the history and exam elements are no longer used for the office visit and other outpatient categories any longer, they would still be expected documentation as medically appropriate to support medical necessity of the visit. After all, CMS continues to view medical necessity as the overarching criteria in determining the level of service and MDM and medical necessity are not the same thing.

And finally, keep in mind that all other E/M categories would continue to use either the 1995 or 1997 guidelines to select the level of service and the time requirements have not changed for any other category.

Written by Cori Bowmer, CPC, CFPC, CPMA, CPPM, CRC

To access RMC’s Compliance Connections Newsletter Qtr 1 2021 in pdf format click here