2021 Updates to Evaluation and Management (E/M) Guidelines

What’s new and different in 2021? 

The new year brings some exciting new changes to the guidelines for evaluation and management services. To reduce the administrative burden, the E/M documentation guidelines have been updated to provide more flexibility and allow providers to spend more time focusing on patient care and less on documentation and coding. 

Beginning in CY2021, providers will have new options for documenting and reporting E/M visits.   

E/M visits may be based on one of the following methods:  

1. The Medical Decision Making level as defined for each service;
   
   OR  
   
   
2. The total time (on the date of the encounter) for E/M services performed  

When performing E/M visits based on medical decision making, all E/M visits require

• a medically appropriate history and/or examination
• an appropriate level of medical decision making

When performing E/M visits based on time alone, selection of the appropriate level will be based on “total time” for E/M services performed on the date of the encounter.  Total time may include both face-to-face and non-face-to-face time spent on certain activities (see below for more detailed information). 

Medical Decision Making 

The medical decision making component of an E/M visit has been simplified and some additional clarity has been provided to aid providers in selecting the appropriate level from one of the four levels.   

1. Straightfoward
2. Low 
3. Moderate 
4. High 

Within each level of medical decision making there are the following three elements of medical decision making: 

1. Number and Complexity of Problems Addressed 
2. Amount and/or Complexity of Data to be Reviewed and Analyzed 
3. Risk of Complications and/or Morbidity or Mortality of Patient Management 

Two out of three elements in any of the four levels must be met to qualify for a particular level of medical decision making. (The AMA has provided a Medical Decision Making Grid to aid providers in selection of the appropriate E/M service code.) 

Time 

CPT® Evaluation and Management (E/M) 2021 allows for using time as the sole factor when selecting the appropriate service level for office or other outpatient E/M codes (99202-99205 and 99212-99215).  This does not apply to the code 99211.  Unlike in the past, time may now be used regardless of whether or not counseling and/or coordination of care is the predominant (greater than 50%) controlling factor in the selection of the level of the E/M service. 

What counts as “Time”? 

When using time as the controlling factor in code selection, both face-to-face and non-face-to-face time “personally” spent by the physician and/or other qualified health care professional(s) will count provided the time is spent on the date of the encounter. Note: Time does not include time on activities that would be normally performed by clinical staff. 

The following activities when performed “personally” by a physician or other qualified health care professional may be counted toward total time: 

• Visit preparation (for example, review of test result(s)). 
• Reviewing and/or obtaining medical records including history from other providers 
• Performance of an evaluation and/or examination that is medically appropriate 

• Providing counseling or education to a patient and/or family/caregiver 
• Order entry for medications, tests, or other procedures 
• Making referrals and other communications with consulting health care professionals *  
• Completing clinical documentation in the EHR or other health record 
• Independent interpretation of results * and communication of results to the patient and /or family/caregivers 
• Other coordination of care 

Note: Time spent on these items may be counted when they have not been separately reported 

When using time as the controlling factor, time is defined by the E/M service descriptors (see table below) 

Prolonged Services 

Often in the office setting physicians, other qualified health care professionals and clinical staff spend time with the patient during an E/M visit that exceeds the time Intervals for face-to-face time for a given level of E/M service. This additional time is considered “prolonged” service.   Determining the appropriate add-on code for reporting prolonged services in the office or other outpatient setting can be confusing.  These add-on codes used for reporting prolonged services in the office and outpatient setting are divided into two types:  

• Prolonged services by clinical staff under the direct supervision of the physician or other qualified health professional (99415, 99416) 
• Prolonged services by the physician or other qualified health care professional (99354,99355. 99XXX) 

Additional rules apply when using these add-on codes.  Review pages 14-16 of the AMA’s CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes for more information and time requirements for each code. 

Counting time in Shared or Split Visits 

When a physician and other qualified health care professional performs a shared or split visit (i.e. providing both a face-to-face visit and related non-face-to-face work jointly) the sum of the time “personally” spent by the physician or other qualified health care professional assessing and managing the patient (on the date of the encounter) will be used to determine the total time.  Further, if the physician or qualified health care professionals meet jointly, only the time of one individual should be counted toward the total time. 

Note: The information provided herein is for educational purposes only and is not intended to be construed as coding or billing advice. Please refer to the source documents below for more detailed guidance.  

References 

https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management 

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf 

https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf 

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf 

https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf