E/M 2021: Grasp the Future Roles of Time and MDM for Accurate Coding

doctor providing E/M service

Evaluation and management (E/M) code descriptors for office and other outpatient visits will look a lot different in the 2021 CPT® code set. One of the first steps in preparing for this major overhaul is understanding how medical decision making (MDM) and time will affect 99202-99215 in 2021.

Quick background: The American Medical Association (AMA), which maintains the CPT® code set, has announced that the 2021 code set will not include level-one new patient code 99201, and codes 99202-99215 will have revised guidelines and descriptors. These changes were in response to Medicare’s plans to revise office and outpatient E/M coding to focus on time and MDM.

Both time and MDM have been important E/M concepts for many years, so you will have to be careful not to fall into old habits when you start applying the new rules in 2021.

See MDM’s Place in Revised Codes

The new E/M coding rules will allow you to choose from new patient codes 99202-99205 and established patient codes 99212-99215 based on either MDM or time. (Established patient code 99211 will still be valid, but the descriptor will not reference MDM or time.) First let’s look at MDM.

The current structure of the office and outpatient E/M codes uses history, examination, and MDM as the three key components for determining the correct code level. In contrast, the 2021 E/M office and outpatient E/M codes will state the level of MDM required for a service (when coding based on MDM rather than time), but won’t require specific levels of history or exam.

For instance, the 2020 descriptor for new patient code 99203 includes the phrase “requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity.”

In 2021, the descriptor for 99203 will instead state the code “requires a medically appropriate history and/or examination and low level of medical decision making.”

Spend Time With New MDM Guidelines

To help you determine the correct MDM level, the 2021 CPT® guidelines will add more specific information, including a new MDM table, which is similar to the Table of Risk in the CMS 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. (The 1995 and 1997 Documentation Guidelines will be obsolete in 2021 for office/outpatient visits.)

The 2021 MDM table will have columns with these headers:

  • Code
  • Level of MDM (Based on 2 out of 3 Elements of MDM)
  • Number and Complexity of Problems Addressed
    • The rows provide the level required for each code. For instance, 99202 and 99212 have a “Minimal” requirement, which the table states is one self-limited or minor problem.
  • Amount and/or Complexity of Data to be Reviewed and Analyzed/*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.
    • The rows include the levels that match the codes and the requirements for reaching that level. As an example, the row for 99203 and 99213 lists “Limited” as the level. To reach that level, you have to meet the conditions listed under either “Category 1: Tests and documents” or “Category 2: Assessment requiring an independent historian.”
  • Risk of Complications and/or Morbidity or Mortality of Patient Management
    • The rows list the levels, and the highest two levels include examples, such as “prescription drug management” under the “Moderate” level on the row for 99204 and 99214.

There are more details in the 2021 MDM table and guidelines, so be sure to work your way through those as you prepare for the 2021 updates. Pay particular attention to the definitions included in the guidelines, such as those for acute and chronic illnesses, to help you use the MDM table correctly.

Adjust to New Meaning for Office/Outpatient Time

When you don’t use MDM to choose a code from 99202-99215, you will be able to use time. How you count the time and when you can use time to determine your code choice will change from 2020 to 2021.

In 2020, you can use time as the deciding factor for your E/M code only when counseling, coordination of care, or both take up more than 50 percent of the encounter. The 2021 changes for 99202-99205 and 99212-99215 will mean that you can use time as the deciding factor for your code choice even when counseling and coordination of care don’t dominate the visit.

Another important change is that the term “time” in 2020 means intraservice time, which is face-to-face time with the patient or family in the office or outpatient setting. For 2021, rather than using intraservice time, you will use total time, which includes face-to-face and non-face-to-face time spent by the E/M provider. You won’t include time spent on separately reported services or time spent on activities the clinical staff usually performs when you determine the total time.

Each 2021 office or outpatient E/M code level will specify the time range that applies to the code:

New patient codes:

  • 99202: 15-29 minutes
  • 99203: 30-44 minutes
  • 99204: 45-59 minutes
  • 99205: 60-74 minutes

Established patient codes:

  • 99212: 10-19 minutes
  • 99213: 20-29 minutes
  • 99214: 30-39 minutes
  • 99215: 40-54 minutes

CPT® also will introduce a new add-on code in 2021 for you to use for prolonged office or outpatient E/M services. You’ll report the code once for each 15 minutes in addition to 99205 or 99215.

Remember the Outlier 99211

For office or outpatient E/M, the exception to the new MDM and time rules will be 99211.

The 2021 descriptor will be similar to the 2020 descriptor, but will remove the crossed out time reference: 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. Typically, 5 minutes are spent performing or supervising these services.

The guidelines state that one appropriate use of 99211 will be when the billing provider’s time is spent supervising the clinical staff who perform the face-to-face part of the encounter.

What About You?

What questions do you have about the 2021 E/M coding changes for office and other outpatient services?  We’ll be covering the E/M 2021 updates throughout the year to help you be ready for this major change.

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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3 Comments For This Post

  1. Erika Ortega Says:

    The amount and/or complexity of data to be reviewed and analyzed. I have difficulty with interpreting this guideline. I do not see a change from the previous years for crediting review and/or order of labs/tests towards the MDM Data; however, I have read and heard that for 2021 physicians must document additional information for “analysis” of data? Before, my understanding was that we credit labs or tests ordered or “resulted” in the note towards MDM Data even if no specific interpretation was noted on the side. What is the change for 2021 E/M?

    Thank you.

  2. carol anderkay Says:

    What is the documentation expected to look like when provider is billing based on time. Can he/she document the total time of the visit and list the activities that were performed? If billing based on time, is a history and exam still required?

  3. Beverly Prudhomme Says:

    Any word on which commercial carriers are adopting the new guidance?

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