Every year payers and public health institutions like the Centers for Medicare and Medicaid Services and the American Medical Association implement changes to their Evaluation and Management coding. Like clockwork, these changes were implemented on January 1, 2021.

Physicians and medical practices of every scale need to educate themselves and their staff on these changes to minimize any delays and reduce the risk for potential questions when filing a claim or requesting prior authorization. This also helps ensure that your practice’s EHR (Electronic Health Records) is up to date with these new modifications.

It’s no secret that E/M coding can be confusing at times. Thankfully the new Evaluation and Management coding changes implemented for 2021 were designed to provide added clarity around things like reimbursement rates and other common coding situations, while also helping to reduce some unnecessary paperwork.

What Are Evaluation and Management Codes?

Evaluation and Management or E/M codes refers to a series of Category I CPT codes in the numerical range from 99201 to 99499. These codes are designed to classify the medical services a physician uses when evaluating a patient or determining the best way to manage their health care. These E/M codes then play a critical role in reimbursement from third-party payers, like medical insurance companies or public health institutions.

A physician often uses E/M codes to help describe services performed during diagnostics or treatment and can be influenced by the total amount of time they spend with a patient in a given session or throughout a day. Say for example, that the physician spends between 45 to 59 minutes related to a patient’s care. They would then use CPT code 99204 to get reimbursed for their services, as it is the code that’s most applicable to that time frame.

This includes a wide range of things like:

  • Preparing the clinical site for the patient’s visit
  • Reviewing the patient’s medical history
  • Performing diagnostic examinations and evaluations
  • Orderings tests, and medications or performing necessary procedures
  • Updating the patient’s information in the EHR
  • In the case of a minor or a vulnerable adult, it could include communicating with the patient’s family

Important Changes For New 2021 E/M Codes

E/M Codes Based on Medical Decision-Making or Total Time

In the past, physicians used Codes 1995 or 1997 to note the time spent on a patient’s office visit. The updated 2021 E/M codes can now be implemented based on the total time used for things like medical decision making.

Evaluation & Management Time Changes

The 2021 updates on E/M codes and how they impact the time of service has been redefined. It is now based on the amount of time that a physician spends on a patient’s care throughout the day of the encounter. This goes beyond face-to-face interactions. This includes other health care providers who might also spend non-face-to-face time providing a patient with care on a specific date.

The total time can also include other important tasks such as updating and documenting the patient’s information in the Electronic Health Record. Though it does not typically include services performed by the nursing or in-house administrative staff.

It’s also worth noting that the “Total Time” is only influenced by that single day. If a physician completes documentation on a different day, the updated E/M code does not let it count towards the total time. For some small practices and solo practitioners, this change could have a significant impact on the number of scheduled appointments in a given day, or the amount of time between scheduled appointments, to ensure that the total E/M time is being used appropriately.

In the past, CPT code 99202 meant the physician spent up to 20 minutes face-to-face with a new patient. The updated 2021 E/M code 99202 means that a physician can bill for 15 minutes to 29 minutes of total time spent on the day of the encounter.

The Updated 2021 Changes Reduce The Burden Of Documentation

There are a few different ways that the 2021 E/M updates help reduce the burden of documentation time. Right of the bat, physicians can use simplified time increments to choose the best possible CPT code to represent the services the patient needs. It also reduces the physician’s concerns about confusing terms such as “The Midpoint” or “Threshold” when selecting the most appropriate E/M code. This translates into less time spent determining the most applicable code, and more time being able to focus on providing patients with care.

At the same time, the E/M selection process is essentially broken down into two key components that are based on the Medical Decision Making time or the total time. The physician doesn’t need to include other elements that might not be considered medically necessary to the patient’s treatment. This in turn helps to streamline the workflow, while providing physicians more time to focus on relevant information as well as the patient’s scheduling needs.

MDM Element Titles That Have Changed

Thankfully, the 2021 updates to much of the MDM table remain unchanged. Though some elements have different or revised titles that better reflect the decision-making process.

Code 99201 Is Not A Viable Option

In the past, physicians could use CPT code 99201 to describe new patients who received E/M services in a clinical setting or an outpatient facility. These face-to-face visits typically involved a lot of direct medical decision-making, and often only took 10 minutes or so to complete. Though the 2021 E/M codes updates have completely removed code 99201 and replaced it with code 99202 instead.

Changes To History & Physical Exam Elements

Under the updated 2021 E/M codes the history and examination components are no longer factored into the key elements of the E/M service. Instead, history and examination elements are only required for E/M reporting in cases where they are medically mandated. However, the history and physical exam elements might not be required for coding purposes.

This ultimately means that clinicians still need to document these components to ensure that they are providing their patients with the highest quality care, while accurately representing their medical history. This is especially important for preventing fragmented care in patients who may need to see multiple specialist physicians for the same condition.

Updates To The Prolonged Service CPT Code

The 2021 updates also include a new add-on CPT code 99417, for billing an E/M service that took longer than 15 minutes for a new or a previously established patient. Though a physician can only use this updated add-on code when they select an E/M service that is based on the total time of services rendered.