Every year we take direction from the most recent CPT® code book, but it’s important to recognize that it doesn’t have the final say on how to document and code evaluation and management (E/M) visits. For the latest guidance, you need the 2021 CPT® Errata and Technical Corrections.
Following the implementation of the updated E/M guidelines for office or other outpatient (CPT® codes 99202-99215) and prolonged services (CPT® codes 99354, 99355, 99356, 99417) in January, the American Medical Association (AMA) received quite a bit of provider feedback regarding areas of confusion. To mitigate uncertainty and minimize ambiguity, the AMA’s CPT® Editorial Panel approved changes to the guidelines for outpatient visits at its February meeting. The AMA posted the additional guidance on March 9, but it is retroactive to January 1.
The approved technical corrections — “clarifications of original Panel intent for the current code structure” — make important changes to the guidelines, with most of the new information concentrated in the medical decision making (MDM) definitions for office and other outpatient visits. Here’s an overview of what’s new.
Two modifications to the general E/M guidelines elucidate the following concepts:
- Activities that don’t count toward a time-based visit.
- Separately reported tests and interpretation.
The rest of the changes apply exclusively to MDM-based office visits:
- Expansion of the number and complexity of problems addressed guideline. It expounds on the concept of morbidity and explains how risk is defined for this element (risk from the condition), which is distinct from the risk associated with management (Risk element).
- Modification of the instructions for selecting a level of office or other outpatient services to provide more information on when to count an ordered test. They further clarify the need for documentation when a test is considered but not performed after shared decision making.
- Addition of five new MDM definitions:
- Analyzed – for reporting tests in the data column.
- Unique – what constitutes unique test and unique source.
- Combination of data elements – allows different data elements to be summed.
- Surgery – minor vs. major, elective vs. emergency, risk factors
- Revision of four MDM definitions to better explain the following terms:
- Drug therapy requiring intensive monitoring for toxicity
- Independent historian
The CPT® Editorial Panel does not have a set schedule for updates and may make additional changes to the E/M guidelines as issues arise that require clarification. This off-schedule update should serve as a reminder to bookmark the Errata & Technical Corrections page and check it periodically.
For more information on the changes, see the AMA’s Errata and Technical Corrections – CPT® 2021