For the first time since 1997 the American Medical Association (AMA), in collaboration with the Centers for Medicare and Medicaid Services (CMS), will implement significant changes to the Evaluation and Management (E/M) office visit codes and guidelines. This paper provides an overview of the E/M changes that will be implemented January 1, 2021.
Background and Context
In July 2018, CMS released the proposed 2019 Medicare Physician Payment Schedule Proposed Rule. This proposed rule called for significant changes to the E/M office visit codes in order to achieve administrative simplification and collapse payments for these services. Feedback to CMS was overwhelming and CMS did not implement the proposed changes. However in response, the CPT Editorial Panel Co-Chairs and RUC Chair formed a workgroup. The workgroup’s objective was to obtain broad input on a revised code structure for E/M office visits that would simplify the provider documentation burden and provide CMS with a workable alternative. The general principles of the work group were to:
- Decrease administrative burden of documentation and coding
- Promote coding consistency and decrease the need for audits
- Decrease unnecessary documentation in the medical record that is not needed for patient care
- Ensure that payment is resource based, regardless of the physician specialty
The result of this effort is significant revisions to the targeted E/M codes which have the potential to reduce physician burden and improve patient care. In June 2019, The AMA released the revised set of E/M codes and guidelines for Office or Other Outpatient codes (99202-99204 and 99212-99215) that will be used on/after 1/1/2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
Summary of Code Changes
- Deletion of code 99201 (“Office or other outpatient visit for the evaluation and management of a new patient with a problem focused history and examination with straightforward medical decision making (MDM)”). Under the new structure, code 99201 is redundant as both 99201 and 99202 require straightforward MDM.
- Components for selecting the E/M code level are changed:
- Clinicians may use either medical decision making or the total time on the date of the encounter to select an E/M service level code.
- There must be a medically appropriate history and/or examination on each visit, but there is no required level of history or physical exam documentation needed to support the E/M code level. The extent of history and physical examination is no longer an element in selection of office or other outpatient services.
- There are new definitions and clarification of the MDM component. The MDM calculation will be similar, but not identical to the current MDM calculation.
- Time will be defined as total time spent, including non-face-to-face work done on that encounter date, and will no longer require time to be dominated by counseling. Visits have a range for time, e.g., 99213 will be 20-29 minutes, 99214 will be 30-39 minutes. The total time must be explicitly documented.
- Finally there will be a new shorter 15-minute prolonged service code (99XXX). This code will be reported only when the visit is based on time and after the total time of the highest-level service (i.e., 99205 or 99215) has been exceeded
The table below provides the revised 2021 E/M codes for both new and established patient office visits.
| Code | Description | Total Time |
| NEW Patient Office Visits | ||
| 99201 has been deleted. To report, use 99202 | N/A | |
| 99202 | Office or other outpatientvisit for the evaluation and management of a new patient, which requires: a medically appropriate history and/or examination and straightforward medical decision making | When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter. |
| 99203 | Office or other outpatientvisit for the evaluation and management of a new patient, which requires: a medically appropriate history and/or examination and low level medical decision making | When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter. |
| 99204 | Office or other outpatient visit for the evaluation and management of a new patient, which requires: a medically appropriate history and/or examination and moderate medical decision making | When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter. |
| 99205 | Office or other outpatient visit for the evaluation and management of a new patient, which requires: a medically appropriate history and/or examination and high level of moderate medical decision making | When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter. For services 75 minutes or longer, see Prolonged Services 99XXX |
| ESTABLISHED Patient Office Visits | ||
| 99211 | Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal | N/A |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient, which requires: a medically appropriate history and/or examination and straightforward medical decision making. | When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter. |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient, which requires: a medically appropriate history and/or examination and a low level of medical decision making. | When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. |
| 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 a moderate level of medical decision making | When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. |
| 99215 | Office or other outpatient visit for the evaluation and management of an established patient, which requires: a medically appropriate history and/or examination and a high level of medical decision making. | When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter. For services 55 minutes or longer, see Prolonged Services 99XXX |