Revised Evaluation and Management Codes in 2021

Revised Evaluation and Management Codes in 2021

The American Medical Association (AMA) strongly disagreed, and the AMA’s CPT® panel got to work on revisions. It takes time to revise CPT® codes and definitions., but the CPT® editorial panel made changes in 2019 that will take effect in 2021. There wasn’t time to put these changes in the 2020 book, and the guidelines and code definitions are unchanged in 2020 for 99201-99215.

As of January 1, 2021, there will be significant changes to the office and outpatient Evaluation and Management (E&M) services (CPT ® codes 99202-99215) for both new and established patients. Practices, physicians, and staff must be aware of the modifications to ensure a successful transition next year and avoid any disruption in reimbursement.

CPT ® code 99201 (new patient, level 1) will be deleted

CPT ® code 99201 is rarely reported by oncologists, and therefore it’s deletion will have a relatively minimal impact on oncology practices. CPT code 99211 (established patient, level 1) will remain as a reportable service.

History and examination will be removed as key components for selecting the level of E&M service.

Currently, history and exam are two of the three components used to select the appropriate E&M service. In 2021, history and exam will no longer be used to select an E&M service, but still must be performed in order to report CPT® codes 99202-99215.

Criteria for code selection

In 2021, E&M code selection will be based on either 1) The level of medical decision making (MDM) OR 2) The time performing the service on the day of the encounter.

Definition of time

The definition of time associated with CPT ® codes 99202-99215 has been revised from the typical face-to-face time to total time spent on the day of the encounter. The total time corresponding to CPT ® codes 99202-99215 have been defined as specific intervals. For example, in order to report 99215, 40-54 minutes of total time must be spent on the date of the encounter. Currently, the time requirement for 99215 is “typically” 40 minutes.

Medical decision-making elements

The medical decision-making elements associated with codes 99202-99215 will consist of three components: 1) The number and complexity of problems addressed 2) Amount and/or complexity of data to be reviewed and analyzed AND 3) Risk of complications and or morbidity or mortality of patient management.  In order to select a level of E&M service, two of the three elements must be met or exceeded. A new medical decision-making table further outlines the criteria for the E&M code level selection.

New Prolonged Services CPT Code

A new prolonged services code (with or without direct patient contact) has been created to describe a prolonged office and outpatient E&M service of 15 minutes beyond the total time of the primary E&M procedure (either CPT® code 99205 or 99215). It can only be reported when the E&M service has been selected based on time alone (not medical decision making) AND only after the total time of a level 5 service (either 99205 or 99215) has been exceeded.

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