Begin to Understand 2021 E/M Guidelines



Get answers to the top 10 questions about coding for office and other outpatient services in 2021.

Ever since the release of the new 2021 evaluation and management (E/M) guidelines for office and other outpatient services, AAPC has been conducting numerous trainings through webinars, virtual workshops, conference sessions, online courses, and multiple articles in Healthcare Business Monthly and the Knowledge Center blog. In this article, we will answer the top 10 questions we have been receiving and then review changes you can expect in 2023.

Top 10 Questions Answered

1. Can the new 2021 guidelines be used for other services (e.g., emergency department)?

No. The 2021 guidelines are specific to office visits reported with 99202-99215.

The American Medical Association (AMA) E/M workgroup focused on the office/other outpatient category because it is the most used, by far. This creates a challenge, however, when your provider performs services both in the office and in other locations (e.g., inpatient hospital services). When training your providers on the E/M changes for 2021, be sure to make that distinction.

2. Can the Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 documentation guidelines still be used?

You should continue to use the CMS 1995 and/or 1997 Documentation Guidelines for Evaluation and Management Services for all E/M categories except office/other outpatient services (99202-99215). Use the 2021 CPT® documentation guidelines for office visits (99202-99215), only.

3. Do you have to document both total time and medical decision making (MDM)?

The provider is not required to document both total time and MDM. They can select whether total time or MDM best represents the work performed for each encounter. The provider can use the criteria that are most advantageous for each patient seen.

During our provider documentation trainings, we asked whether providers thought total time or MDM best represented their work and the majority answered MDM. There will be instances where total time represents the work done better than MDM. For example, instances when the patient has multiple tests or treatment options that must be reviewed, or the patient/caregiver has a lot of questions, basing code selection on time may allow you to report a higher-level visit that more accurately represents the provider’s work.

4. What is the best way to document total time?

To properly document total time, the provider needs to document the activities performed and include a statement of the total time for the encounter. Because you cannot include the time spent performing other billable services (for example, interpretations that are billed separately, minor procedures, care coordination), it is recommended that the provider includes a statement that the total time does not include the time spent performing other billable services.

We have been asked if it is required to document the time increments associated with each activity (for example, 5 minutes spent reviewing records, 10 minutes spent examining the patient and answering all their questions, and 10 minutes ordering tests and documenting in the medical record). There is not an official source stating that time must be documented incrementally, just that total time must be documented.

5. If you are coding based on total time, does the time a medical scribe spends documenting in the electronic health record count?

No, only the activities the provider personally performs can be included in determining total time. Clinical staff time cannot be included in the total time billed for the E/M code. We are also often asked if you can count resident time. The answer is no to that, too. The teaching physician guidelines have not changed. When residents are involved in performing any service that is coded based on time, only include the time of the teaching physician.

6. How do you bill for an E/M and minor procedure on the same date of service?

If coding the E/M service based on time, make sure the time spent performing the minor procedure is not included in the total time used to determine the E/M code. If selecting the E/M code based on MDM, you do not need to include that distinction in the documentation.

There is still the requirement that the services must be separately identifiable to report the E/M service with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service and the code for the minor procedure. If the patient is presenting for the minor procedure and a separately identifiable E/M service is not performed and documented as such, report the minor procedure only.

7. Can you count the order of a test that is interpreted and billed by the provider?

If the provider is performing and billing the interpretation, the order cannot be counted as data under MDM. The AMA’s technical correction states, “The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.”

8. Can you count the order of a test on one date of service and the review of the same test when the patient returns for the next encounter?

No. You can count the ordering of the test during the visit when it’s ordered, but the subsequent review is expected to be performed when the test is ordered. You cannot give credit for the review of a test if credit was already given for the order.

This makes sense if you think of this scenario in the practical sense of how patient care is delivered. The patient is seen, and the provider orders tests. The provider will likely review the test results as soon as they become available. The provider will rarely wait until the next face-to-face encounter with the patient to review the test results.

Another typical scenario is the provider orders tests when the patient is seen, reviews the test results, and based on the results, orders additional tests. In this scenario, you would give credit for the review of the results of the next series of tests because they were ordered after the patient was seen and the order was not counted as data at the previous visit.

9. Why are there different codes for prolonged services for CMS and CPT®?

When coding based on total time, there are new prolonged services codes that can be used when the level 5 time is exceeded. CMS and CPT® have a difference of opinion on when the time of the level 5 visit is exceeded.

According to CPT®, 99417 Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time … each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services) can be reported for a new patient after 75 minutes is met and for an established patient when 55 minutes is met. There is a table in the CPT® code book that shows the time segments, codes, and units of 99417 that can be reported.

According to CMS, G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time … each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact can be reported for a new patient when 89 minutes is met and for an established patient when 69 minutes is met.

CPT® adds the 15 minutes to the lowest or highest time assigned to the level 5 code. For example, new patient E/M code 99205 is a total time of 60-74 minutes. An additional 15 minutes to the minimum 60 minutes equals 75 minutes; an additional 15 minutes to the maximum 74 minutes equals 89 minutes.

10. When reviewing an external note, does each test and progress note count separately?

No, all the information from the unique source would be counted as one data element. This is clarified in the technical corrections released in March 2021 by the AMA: A unique source is defined as a physician or qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.

Changes to Come in 2023

After each CPT® Editorial Panel meeting, the AMA posts the actions of the panel. In 2023, you will see many changes to the codes and guidelines in the other categories of E/M. It was always the intent of AMA and CMS to revise the other categories of E/M once the changes for the office visits were implemented.

The details of the changes have not been released, but we do know you can expect the following:

  • Inpatient and observation services
    • Deletion of codes for observation discharge (99217), initial observation (99218, 99219, 99220), and subsequent observation (99224, 99225, 99226) 
    • Revision of codes and guidelines for initial hospital care (99221-99223), subsequent hospital care (99231-99233), admission and discharge on the same date of service (99234-99236), and hospital discharge (99238, 99239)
  • Consultations
    • Deletion of codes 99241 and 99251
    • Revision of other codes and guidelines
  • Emergency Department Services
    • Revision of codes 99281-99285 and guidelines
  • Nursing Facility Services
    • Deletion of annual nursing facility assessment code 99318
    • Revision of all other codes and guidelines
  • Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services
    • Deletion of the codes and guidelines 
  • Home Services
    • Revision of all codes and guidelines
  • E/M services guidelines
    • Revision of MDM table to support changes in other categories

Until these changes go into effect in 2023, code office visits using the 2021 CPT® guidelines and CMS 1995 and 1997 documentation guidelines for all other categories. With this summary of changes published, you can expect future guidelines and revised code descriptions to be more consistent with the changes that were implemented for office visits in 2021.

Evaluation and Management – CEMC

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