Evaluation & Management - Coding Changes for 2021




Providers always used history, examination, medical decision-making and time to determine the level of Evaluation & Management service. The recent update to the Evaluation & Management service, coding guidelines will be determined on two factors:

1. Level of service - by medical decision-making for the service


Medical decision-making will be decided on Straightforward, Low, Moderate or High.


These levels are outlined by AMA:


CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.



2. The total time it took to perform Evaluation & Management services on the date of the encounter.


It includes the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional on the day of the encounter (It does not include time in activities normally performed by clinical staff).


Documentation is mandatory for audit purpose, and the Evaluation & Management update applies only to the following Evaluation & Management codes:


• 99202-99205 New Patient Codes

• 99211-99215 Established Patient Codes



Time Determination

• Preparing to see the patient (e.g., review of tests)

• Obtaining and/or reviewing separately obtained history

• Performing a medically appropriate examination and/or evaluation

• Counseling and educating the patient/family/caregiver

• Ordering medications, tests, or procedures

• Referring and communicating with other health care professionals (when not separately reported)

• Documenting clinical information in the electronic or other health record

• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver

• Care coordination (not separately reported)


New Patient Codes

CPT code 99201 has been deleted for 2021 and replaced by CPT code 99202.


• 99202 is used when 15-29 mins of total time is spent on the date of the encounter

• 99203 is used when 30-44 mins of total time is spent on the date of the encounter

• 99204 is used when 45-59 mins of total time is spent on the date of the encounter

• 99205 is used when 60-74 mins of total time is spent on the date of the encounter


Established Patient Codes

CPT code 99211 would never be reported when a physician is present.


• 99212, is used when 10-19 mins of total time is spent on the date of the encounter

• 99213, is used when 20-29 mins of total time is spent on the date of the encounter

• 99214, is used when 30-39 mins of total time is spent on the date of the encounter

• 99215, is used when 40-54 mins of total time is spent on the date of the encounter


Use +99XXX (Prolonged Service when the Evaluation & Management service goes beyond the 54 mins with 99215 or the 74 mins with 99205.)


• CPT code +99XXX should be reported in 15 minutes. Use 99XXX in conjunction with 99205, 99215. Additional information on prolonged services is also outlined by the AMA, on the last page, in the following link: Total Duration of New Patient Office or Other Outpatient Services.



Prepare for 2021 Changes:

• Sign up your staff for any additional training that is available through Medicare, AMA or any associations that your office is a member of.

• Approach your Practice Management Software to ensure codes are added and confirm documentation requirements are being met.

• Ensure with your clearinghouse that new codes will be accepted come January 1st, 2021.

• Make sure that your staff be up to date on changes and implementation as it comes.



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