What Is the Correct Cpt Code for Physician Reviewed the Medical Record and the Recent Lab Results

99202-99215: Office/Outpatient E/Chiliad Coding in 2021

Healthcare professionals across a broad range of specialties report evaluation and direction (E/M) CPT^® codes on insurance claims to request reimbursement for services performed in the office or other outpatient setting.

The American Medical Association (AMA), which holds copyright in CPT^®, and the Centers for Medicare & Medicaid Services (CMS) implemented major revisions related to office and outpatient E/M codes 99201-99215 in 2021. One goal of these changes was to streamline the coding and documentation requirements for these commonly reported codes.

Part/Outpatient E/Thousand Coding Before 2021

To understand the 2021 East/1000 coding changes, y'all demand to know the basics of how E/M coding worked previously.

AMA's 2020 CPT^® code fix included guidelines on using patient history, clinical test, and medical decision making (MDM) to determine the correct level of E/M codes. The guidelines too offered information on how to apply time to select Due east/M codes when counseling, coordination of care, or both made upwardly more than 50% of the intraservice fourth dimension.

Non all Eastward/M codes use history, examination, MDM, or time for lawmaking selection, but function and outpatient visit codes 99201-99215 were among those that did in 2020. For instance, note the references to history, exam, and MDM, as well as the typical fourth dimension spent, in these 2020 CPT^® code descriptors for level-three E/M codes 99203 and 99213 (assuming added for emphasis):

99203

Office or other outpatient visit for the evaluation and management of a new patient, which requires these iii fundamental components: A detailed history; A detailed test; Medical conclusion making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(south) and the patient'south and/or family unit'southward needs. Unremarkably, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face up-to-face with the patient and/or family.

99213

Office or other outpatient visit for the evaluation and management of an established patient, which requires at to the lowest degree 2 of these three key components: An expanded problem focused history; An expanded trouble focused examination; Medical decision making of depression complexity. Counseling and coordination of intendance with other physicians, other qualified wellness care professionals, or agencies are provided consequent with the nature of the problem(south) and the patient'south and/or family's needs. Normally, the presenting problem(due south) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

CMS' 1995 and 1997 Documentation Guidelines for Evaluation and Direction Services provide more details than the CPT^® guidelines on how to select a final E/M code based on the key components or fourth dimension. But at xvi pages and 49 pages respectively, these Documentation Guidelines create a lot of work for coders and providers. The Documentation Guidelines are also more than than 20 years old, which is a long time in the always-evolving earth of healthcare.

MPFS 2019 Plans for Office/Outpatient E/Yard in 2021

There take been many calls to simplify E/1000 coding over the years, but the 2019 Medicare Doc Fee Schedule (MPFS) rule is specially helpful for agreement the groundwork of the 2021 Eastward/1000 updates.

The MPFS is funded past Medicare Part B and is a listing of fee maximums Medicare uses to pay physicians and other healthcare professionals on a fee-for-service basis. Each year CMS publishes a proposed rule and a concluding rule explaining changes planned for the adjacent year's MPFS.

The 2019 MPFS final dominion included substantial changes for E/M office outpatient codes 99201-99215. The stated goals were reducing administrative brunt, improving payment accuracy, and updating the code set to reverberate electric current medical practice.

One policy change in the 2019 MPFS terminal rule that got a large reaction from providers was a plan to pay a single charge per unit, called a blended rate, for E/M visit levels 2 to iv starting in 2021. In other words, Medicare intended to pay the same rate for new patient codes 99202, 99203, and 99204, regardless of which lawmaking was reported. Medicare was going to pay another single rate for established patient codes 99212, 99213, and 99214. Level-5 visits (99205, 99215) would accept divide rates to reflect the increased complexity those codes represent.

Although this plan for blended rates was in the 2019 final dominion, Medicare later stated this fee-construction change would non go through. The MPFS continues to listing distinct payment rates for each office/outpatient E/M code in 2021. Medicare eliminated the blended rates because of E/M code revisions and new valuation data AMA produced in response to the MPFS programme. Y'all will read more nearly those codes in the sections below.

The 2019 MPFS final rule as well indicated Medicare would allow practitioners to document office and outpatient levels 2 to 5 using merely MDM or time starting in 2021. Providers would be immune to continue to employ the 1995 and 1997 Documentation Guidelines as the basis for their coding if they preferred. Notwithstanding, as you will run into, AMA'southward 2021 E/M lawmaking revisions eliminate the need for utilize of the 1995 and 1997 Documentation Guidelines for office/outpatient E/Chiliad codes.

Another of import alter related to E/M in the 2019 final dominion was a plan to add HCPCS Level 2 G codes (codes that start with the letter One thousand) to reflect additional resource used for chief intendance and sure specialist visits. These codes were intended for use with level two to four visits. A new "extended visit" G code was planned for use with levels two to 4, also, all beginning in 2021. These expectations accept also inverse, as you'll discover after in this article.

AMA's 2021 Office/Outpatient East/Yard Codes: New Patient

As an alternative to Medicare'due south plans, the AMA developed new guidelines and code descriptors for office and outpatient E/M codes. The effective date was January. 1, 2021. Because this update has such a large touch on healthcare providers, the AMA posted the revised 2021 office and outpatient E/Grand guidelines and code descriptors for review before the effective date. Permit'due south outset with the new patient codes and descriptors.

99201: The 2021 CPT^® code set does not include new-patient level-1 lawmaking 99201. As you'll see below, the revised code descriptors for the remaining role and outpatient E/Thousand codes use MDM or fourth dimension to dictate code selection. Code 99201 required straightforward MDM, the same equally 99202, and having 2 codes requiring the same level of MDM would be redundant.

99202-99205: In 2021, new patient codes 99202-99205 no longer require the 3 key components or reference typical contiguous time. Instead, each service includes "a medically appropriate history and/or test," and code selection is based on the MDM level or total time spent on that date.

Compare the 2020 descriptor for 99203 posted earlier in this article to the 2021 code descriptor below:

99203

Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically advisable history and/or examination and low level of medical decision making. When using time for lawmaking selection, 30-44 minutes of full fourth dimension is spent on the appointment of the come across.

The descriptors for 2021 codes 99202-99205 all follow the same construction as the 99203 example higher up. Tabular array 1 shows the requirements for the new patient E/M codes in 2021.

Table 1: 2021 Requirements for E/Thou Codes 99202-99205

Code	History/Exam	MDM	Full Minutes
99202	Medically advisable history and/or exam	Straightforward	fifteen-29
99203		Low	30-44
99204		Moderate	45-59
99205		High	60-74

For services longer than 74 minutes, the AMA created a new prolonged services add-on code, +99417 Prolonged office or other outpatient evaluation and management service(due south) beyond the minimum required time of the chief procedure which has been selected using total fourth dimension, requiring total time with or without straight patient contact beyond the usual service, on the date of the principal service, each 15 minutes of total time (List separately in add-on to codes 99205, 99215 for role or other outpatient Evaluation and Management services).

Medicare created a HCPCS Level II code to use in place of +99417 when coding for Medicare patients. The sections below virtually prolonged services provide more details almost these codes.

AMA'southward 2021 Function/Outpatient E/Yard Codes: Established Patient

The office and other outpatient Eastward/Yard codes for established patients inverse in line with the revisions to the new patient codes in 2021.

99211: Level-i established patient Eastward/M code 99211 is all the same bachelor, but the 2021 code descriptor does not include the time reference that was in the 2020 descriptor:

99211

Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a doc or other qualified wellness care professional person. Normally, the presenting problem(southward) are minimal. Typically, 5 minutes are spent performing or supervising these services.

99212-99215: Established patient Eastward/M codes 99212-99215 look a lot similar the new patient codes in 2021. For instance, review the revised descriptor for 99213:

99213

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically advisable history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the appointment of the encounter.

Table 2 shows the requirements for the 2021 established patient codes. Annotation that the times required for each level differ for the new patient and established patient codes. For instance, level-v new-patient code 99205 lists a time of 60-74 minutes while level-v established-patient code 99215 lists 40-54 minutes.

Tabular array 2: 2021 Requirements for Due east/Thousand Codes 99212-99215

Lawmaking	History/Examination	MDM	Full Minutes
99212	Medically advisable history and/or examination	Straightforward	10-nineteen
99213		Low	twenty-29
99214		Moderate	xxx-39
99215		High	40-54

You may use new prolonged services lawmaking +99417 every bit an addition code with 99215 for services 55 minutes or longer for payers who follow AMA rules. As noted above, Medicare provides a different code for prolonged services, and that lawmaking has its ain rules.

2021 CPT^® E/M Guidelines Overview

Because of the 2021 changes to the office and outpatient Due east/Thousand codes, the CPT^® E/Thou guidelines saw revisions, as well. Some of the guideline updates relate directly to the new lawmaking requirements, but the guidelines as well characteristic changes throughout to ensure no outdated references involving the office/outpatient codes remain.

For example, the CPT^® E/M services guidelines added these headings:

• Guidelines Common to All E/M Services
• Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domicilic, Balance Home, or Custodial Care, and Home E/Grand Services
• Guidelines for Office or Other Outpatient E/M Services

2021 CPT^® E/G Guidelines for Fourth dimension and Separate Services

When reviewing the 2021 Guidelines Common to All E/M Services, pay particular attention to the entries for Time and Services Reported Separately.

Time: The Time department of the 2021 Due east/M guidelines includes important data nigh proper use of the revised function and other outpatient codes. Here are the major points from the 2021 guidelines for Time:

• You lot may utilise time alone to select the right code from 99202-99205 and 99212-99215. Notation that 99211 is not in that listing considering no fourth dimension is listed in that descriptor
• Counseling and/or coordination of care does not demand to dominate an office or other outpatient E/Grand service for you lot to code the service based on time in 2021. But for other E/Grand services that you code based on fourth dimension, you however need to meet the threshold of counseling and/or coordination of care taking upward more 50% of the visit.
• You apply 99211 if clinical staff members perform the contiguous visit under the supervision of the doctor or other qualified healthcare professional person.
• A shared or carve up visit is when a doctor and one or more other qualified healthcare professionals perform the face up-to-face and not-face-to-face work for the Due east/M visit. When you're coding these visits based on fourth dimension, sum the time spent past the physician and other qualified healthcare professionals to become a total time. Y'all should count any time that the providers spend together to see with or discuss the patient only once. For case, if two providers meet for 15 minutes, yous should add 15 minutes to the full fourth dimension, not thirty minutes (xv minutes x two providers).
• A key shift for the office and other outpatient Due east/M codes is that the time referenced in the 2021 code descriptors is total time. The 2020 descriptors for these codes used intraservice fourth dimension.
  • The 2021 Time guidelines explain that for 99202-99205 and 99212-99215, total time on the encounter date includes both face-to-face and non-face-to-face fourth dimension spent past the provider.
  • The guidelines offer the examples of preparing for the visit (such as reviewing tests); getting or reviewing a history that was separately obtained; performing the exam; counseling and providing education to the patient, family, or caregiver; ordering medicines, tests, or procedures; communicating with other healthcare professionals; documenting information in the medical record; interpreting results and sharing that data with the patient, family, or caregiver; and care coordination.
  • When you count time for the 2021 codes, you lot should non include fourth dimension spent on services y'all report separately. For instance, if you report care coordination using a separate CPT^® lawmaking, yous should non include that service's time in the time for the E/M code.
  • The full fourth dimension likewise does not include time for activities the clinical staff commonly performs.

Services Reported Separately: The 2020 CPT^® Eastward/Grand guidelines included data almost services reported separately, but the 2021 guidelines give this information its own heading and add some clarifications. In item, note this line: "If a exam/study is independently interpreted in guild to manage the patient equally part of the Eastward/M service, but is non separately reported, it is part of medical decision making."

2021 CPT^® E/M Guidelines for Office/Outpatient History and Exam

The Guidelines for Office or Other Outpatient Due east/Chiliad Services will aid yous sympathize the revised E/1000 codes and how to apply them in 2021.

The History and/or Exam portion of these Eastward/M guidelines explains that function and other outpatient E/Grand services include "a medically appropriate history and/or physical examination, when performed."

"Medically appropriate" means that the physician or other qualified healthcare professional reporting the Due east/M determines the nature and extent of whatsoever history or exam for a particular service. Recall that code selection does non depend on the level of history or examination. That's why the guidelines don't quantify these elements.

The history and exam guidelines for office and outpatient E/1000 visits also specify that the "care team" may collect information, and the patient (or caregiver) may provide information, such equally past portal or questionnaire. The reporting provider must then review that data.

2021 CPT^® E/M Guidelines for MDM

Because you use either full encounter time or MDM to select the level of office or other outpatient E/Chiliad in 2021, CPT^® clarified and expanded the MDM guidelines, including the improver of a new Level of Medical Decision Making (MDM) table.

The MDM guidelines and table are in the CPT^® Due east/G guidelines section for Instructions for Selecting a Level of Function or Other Outpatient E/M Service, but y'all employ them together with information and definitions in the department called Number and Complexity of Bug Addressed at the Come across.

In the 2021 MDM guidelines, CPT^® states that MDM "includes establishing diagnoses, assessing the status of a status, and/or selecting a direction choice." Three elements define MDM for office/outpatient visits in 2021, and they are similar merely non identical to the 2020 elements:

• ane. The number and complexity of the problem or bug the provider addresses during the Eastward/Yard encounter.
  • In 2020, the guidelines instead referred to "the number of possible diagnoses and/or the number of management options."
• 2. "The amount and/or complexity of data to exist reviewed and analyzed." The 2021 guidelines list three categories for data: (1) tests, documents, orders, or contained historians, (ii) independent test interpretation, and (3) discussion of management or test estimation with external providers or appropriate sources. The latter term refers to not-healthcare, non-family sources involved in patient management, like a parole officer or case manager.
  • The 2020 MDM guidelines also included the amount and/or complexity of medical records, test, and other information involved, but the 2021 guidelines expand the section significantly.
• three. "The risk of complications and/or morbidity or bloodshed of patient direction decisions fabricated at the visit." The 2021 guidelines make it clear that options considered, but not selected, are still a gene for this element, specifically after "shared" MDM with the patient, family, or both. Examples include deciding against hospitalization for a psychiatric patient with sufficient support for outpatient intendance or choosing palliative treat a patient with avant-garde dementia and an astute condition.
  • The 2020 MDM guidelines included comparable wording, only they did not include the reference to shared MDM or the examples found in the 2021 guidelines.

2021 Levels of Medical Decision Making (MDM) Table

The AMA CPT^® Editorial Panel used the Table of Risk that'due south in the CMS 1995 and 1997 Documentation Guidelines, likewise as current CMS contractor audit tools, every bit a footing for the 2021 MDM updates.

The 2021 MDM table in the CPT^® Eastward/Thou guidelines has three main columns with the final column divided into three additional columns:

• Code
• Level of MDM (Based on 2 out of 3 Elements of MDM)
• Elements of Medical Decision Making
  • Number and Complexity of Problems Addressed at the Encounter
  • Amount and/or Complication of Data to exist Reviewed and Analyzed
  • Adventure of Complications and/or Morbidity or Bloodshed of Patient Direction

In Tables 1 and 2 to a higher place, you saw that the MDM required for each distinct code level is the same, regardless of whether the code is for a new or established patient. For example, level-2 codes 99202 and 99212 both require straightforward MDM.

Each row of the CPT^® MDM table shows the requirements for a specific code level, with 99211 on the first row, 99202 and 99212 on the second row, and so on. The 2d cavalcade shows the MDM level for the codes in cavalcade i. The final three columns correspond the 3 elements of MDM.

Table three shows the row from the CPT^® MDM table for codes 99203 and 99213 forth with column headings to give y'all an idea of the structure. Pay attention to the note in the Level of MDM column reminding you that your final option for the MDM level should be based on meeting requirements for two out of the iii elements. (In 2020, the service had to meet two out of iii elements in the much smaller table CPT^® provided for that lawmaking prepare.)

To use the 2021 MDM table properly, you too need to be familiar with the apply of categories in the column for Amount and/or Complexity of Data to be Reviewed and Analyzed.

Every bit Tabular array 3 shows, for 99203 and 99213 the service has to meet the requirements for at to the lowest degree i of 2 categories. For codes 99204 and 99214, the service has to see the requirements for one of three categories. For the highest-level codes, 99205 and 99215, the service has to run across the requirements for ii of three categories. The lower-level codes don't have categories in that column.

Table three: Sample Row from 2021 E/G Table for MDM Level

Lawmaking	Level of MDM (Based on 2 out of 3 Elements of MDM)	Elements of Medical Decision Making
		Number and Complexity of Problems Addressed at the Encounter	Amount and/or Complexity of Data to exist Reviewed and Analyzed *Each unique test, order, or certificate contributes to the combination of 2 or combination of 3 in Category 1 below.	Risk of Complications and/or Morbidity or Bloodshed of Patient Management
99203 99213	Low	Low ·   ii or more self-limited or pocket-sized problems;   or ·   1 stable chronic illness;      or ·   i acute, uncomplicated illness or injury	Limited (Must meet the requirements of at least one of the ii categories) Category one: Tests and documents · Any combination of 2 from the post-obit: o Review of prior external note(due south) from each unique source*; o review of the outcome(s) of each unique test*; o ordering of each unique test* or Category 2: Assessment requiring an contained historian(s) (For the categories of independent interpretation of tests and word of management or test interpretation, run across moderate or loftier)	Low risk of morbidity from additional diagnostic testing or treatment

Number and Complexity of Problems Addressed at the Encounter

The 2021 CPT^® guidelines include a heading for Number and Complexity of Problems Addressed at the Run into (which matches a cavalcade name in the MDM table). This office of the guidelines includes a brief give-and-take about how the problems addressed may impact code level selection. Under this header, y'all'll as well find many definitions that are important to MDM.

One cardinal point the 2021 guidelines make is that the final diagnosis isn't the only factor when you determine the complexity or run a risk. A patient may have several lower-severity problems that combine to crusade college risk, or the provider may have to perform an all-encompassing evaluation to determine a problem is of lower severity.

The 2021 guidelines too take a 2020 rule and aggrandize it, clarifying that you should non consider comorbidities and underlying diseases when you lot select the Due east/Yard level "unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the hazard of complications and/or morbidity or mortality of patient management."

2021 MDM Terms and Definitions

To use the 2021 level of MDM tabular array properly, you lot need to know CPT^®'s definitions for many terms. In fact, you need to know roughly ii pages of definitions. Beneath is an overview of many of those terms, but yous should review the official guidelines to encounter the complete list of definitions.

To authorize every bit a problem addressed (or managed) for office or other outpatient MDM, the provider must evaluate or treat the problem at the encounter. If the provider considers further testing or treatment, but the provider or patient/caregiver decides against information technology, that still counts equally addressed. Merely a simple note that some other professional is managing a problem does not count equally addressed. In that location must be additional assessment or care coordination to see the requirements of addressing a problem. Another surface area that does non authorize equally addressing the trouble is referral without evaluation (past history, exam, or diagnostic studies) or consideration of handling.

A cocky-express or minor problem is defined almost identically by the 2020 and 2021 E/M guidelines, merely the 2021 guidelines delete the crossed out text: "A problem that runs a definite and prescribed course, is transient in nature, and is not probable to permanently alter health status OR has a good prognosis with management/compliance." The MDM tabular array includes the term self-limited or minor problem in the column for Number and Complication of Issues Addressed at the Run into. Level-two codes come across the threshold for "minimal" if in that location is i self-limited or minor problem addressed. Level-3 codes encounter the threshold for "low" if two or more self-limited or minor problems are addressed.

Hazard is related to the probability of something happening, but adventure and probability are not the same for E/M office and outpatient coding purposes. For instance, loftier probability of a minor adverse effect may be depression risk, depending on the case. The AMA intends the terms high, medium, depression, and minimal risk to reverberate the common meanings used past providers in their specialties. For MDM, base the level of adventure on the consequences of the addressed issues when they're appropriately treated. Risk likewise comes into play for MDM when deciding whether to begin further testing, treatment, or hospitalization.

An external physician or other qualified healthcare professional is not in the aforementioned grouping do or is classified as a different specialty or subspecialty. Review of external notes is included in the office/outpatient East/M codes for levels iii to five. Discussion with an external provider is included in levels iv and 5.

An contained historian is a family unit fellow member, witness, or other individual who provides patient history when the patient tin't provide a complete history or the provider thinks a confirmatory history is needed. Cess requiring an independent historian is included in office/outpatient E/M levels 3 to 5.

Social determinants of health (SDOH) are economic and social weather condition that effect wellness. SDOH is something you lot may exist familiar with from ICD-ten-CM coding, specifically categories Z55.- to Z65.-, Persons with potential health hazards related to socioeconomic and psychosocial circumstances. The 2021 MDM tabular array references SDOH in an example of moderate risk from additional diagnostic testing or handling because SDOH, like housing insecurity, may limit those options.

Drug therapy requiring intensive monitoring for toxicity is in the 2021 CPT^® MDM tabular array equally an example of high take a chance of morbidity from boosted diagnostic testing or handling. To be sure the example you're coding qualifies as intensive monitoring for toxicity, review these conditions listed in the guidelines:

• The drug tin can cause serious morbidity or expiry.
• Monitoring assesses adverse effects, not therapeutic efficacy.
• The type of monitoring used should exist the generally accepted kind for that amanuensis, although patient-specific monitoring may be appropriate, besides.
• Long-term or curt-term monitoring is OK.
• Long-term monitoring occurs at to the lowest degree quarterly.
• Lab, imaging, and physiologic tests are possible monitoring methods. History and examination are non.
• Monitoring affects MDM level when the provider considers the monitoring equally part of patient management.
• An instance of drug therapy requiring intensive monitoring for toxicity is testing for cytopenia (reduction in the number of mature claret cells) betwixt antineoplastic agent dose cycles.

Morbidity is a "land of affliction or functional damage that is expected to exist of substantial elapsing during which function is limited, quality of life is impaired, or at that place is organ damage that may non be transient despite treatment." Morbidity is an important term to understand for the acute and chronic illness definitions beneath.

Astute and chronic illnesses are referenced in a variety of ways in the Number and Complexity of Bug Addressed at the Encounter column of the CPT^® 2021 MDM table. Tabular array 4 will help you compare these terms for acute and chronic illnesses.

Table 4: 2021 CPT^® E/M Guideline Definitions for Astute and Chronic Illnesses

Term	Clarification	Examples
Acute, simple illness or injury	·   The problem is recent and brusk-term. ·   There is a low gamble of morbidity. ·   In that location is little to no risk of mortality if treated. ·   Full recovery with no functional impairment is expected. ·   The trouble may be self-limited or minor, but it is not resolving in line with a definite and prescribed course.	·   Cystitis ·   Allergic rhinitis ·   Simple sprain
Acute disease with systemic symptoms	·   The illness causes systemic symptoms, which may exist full general or single arrangement. ·   In that location is a loftier risk of morbidity without treatment. ·   For a minor illness with systemic symptoms similar fever or fatigue, consider astute, unproblematic or self-limited/pocket-size instead.	·   Pyelonephritis ·   Pneumonitis ·   Colitis
Astute, complicated injury	·   Treatment requires evaluation of body systems that aren't part of the injured organ, the injury is extensive, there are multiple treatment options, or there is a chance of morbidity with treatment.	·   Head injury with brief loss of consciousness
Stable, chronic disease	·   This type of trouble is expected to concluding at least a twelvemonth or until the patient's death. ·   A modify in stage or severity does not alter whether a condition is chronic. ·   The patient'southward treatment goals decide whether the illness is stable. A patient who hasn't achieved their treatment goal is not stable, even if the condition hasn't changed and there's no immediate threat to life or function. ·   The risk of morbidity is significant without treatment.	·   Well-controlled hypertension ·   Non-insulin dependent diabetes ·   Cataract ·   Benign prostatic hyperplasia ·   Not stable: Asymptomatic but consistently high blood pressure, with a treatment goal of meliorate control
Chronic illness with exacerbation, progression, or side furnishings of treatment	·   The chronic illness is getting worse, is not well controlled, or is progressing despite the intent to control progression. ·   The condition requires additional care or requires handling of the side effects. ·   Infirmary level of care is not required or considered.	·   No examples given by CPT® guidelines
Chronic illness with severe exacerbation, progression, or side effects of treatment	·   At that place is a significant gamble of morbidity. ·   The patient may crave hospital care.	·   No examples given by CPT® guidelines
Acute or chronic illness or injury that poses a threat to life or bodily function	·   There is a near-term threat to life or bodily part without treatment. ·   An acute disease with systemic symptoms; an acute, complicated injury; or a chronic illness or injury with exacerbation, progression, or side furnishings of treatment (as defined by CPT® guidelines) may exist involved.	·   Astute myocardial infarction ·   Pulmonary embolus ·   Severe respiratory distress ·   Progressive severe rheumatoid arthritis ·   Psychiatric affliction with potential threat to self or others ·   Peritonitis ·   Astute renal failure ·   Sharp alter in neurologic status

Medicare Accepts Most CPT^® East/M Coding and Guideline Changes

The MPFS 2020 final rule addressed the substantial changes that the AMA announced for East/M office/outpatient codes in 2021, stating that Medicare would adopt the MDM guidelines revised past CPT^® and would allow the use of fourth dimension or MDM for office/outpatient E/M lawmaking selection. The last rule as well stated that Medicare would monitor claims to watch for shifts in visit levels billed, including whether certain specialties are affected more than others.

The MPFS 2021 final dominion confirmed that Medicare would generally adopt the AMA code and guideline changes, every bit planned. Only medical coders and providers should stay warning for Medicare rules and payer-specific variations, such as how to code for prolonged services, described below.

2021 E/M Coding for Prolonged Services: CPT^®

Because the part of fourth dimension changed for office and other outpatient E/1000 codes in 2021, the AMA revised the Prolonged Services section of the CPT^® lawmaking ready.

Codes +99354 and +99355 for prolonged E/One thousand services requiring direct patient contact changed from applying to the part or other outpatient setting to applying to the outpatient setting. The descriptors country that you should not use +99354 and +99355 every bit add-on codes with part/outpatient codes 99202-99205 and 99212-99215. The guidelines for these prolonged services codes (and other prolonged services codes) as well saw revisions to factor in new 2021 CPT^® code +99417.

The code descriptor is a good place to start to get to know the new function/outpatient prolonged services lawmaking:

+99417

Prolonged office or other outpatient evaluation and management service(south) beyond the minimum required time of the chief procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of full time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)

Pay special attention to these points in the descriptor:

• Code +99417 applies only when you choose the primary E/M code based on time (not MDM).
• The new code includes total time with and without directly patient contact on the date of service. Recollect that 99202-99205 and 99212-99215 also use full time rather than intraservice time in 2021.
• You will use +99417 once for each 15 minutes across the minimum required primary service fourth dimension.
• There are only two appropriate primary codes: 99205, which represents the longest fourth dimension amongst the new patient codes, and 99215, which represents the longest fourth dimension among the established patient codes.

New CPT^® guidelines that accompany +99417 state you should not report the code for any time period under 15 minutes. Nether CPT^® rules you outset counting based on the minimum time required for the code. For instance, 99205 represents threescore-74 minutes in 2021. You may add together +99417 as shortly as the encounter reaches 75 minutes, which is 15 minutes beyond the minimum required time of sixty minutes. You should non assign some other unit of +99417 until the encounter reaches xc minutes, which is fifteen minutes more than 75 minutes. In other words, y'all assign 99205 and +99417 to study 75-89 minutes. For 90-104 minutes, you should study 99205 and ii units of +99417.

A parenthetical didactics with the code states that you should not study +99417 on the aforementioned date as other prolonged services codes +99354, +99355, 99358, +99359, +99415, and +99416.

Go on in mind that Medicare has created a code to use in place of +99417, equally will be explained beneath.

Medicare-Specific HCPCS Code for Prolonged Services

Medicare created a new HCPCS Level Two code for utilize in place of CPT^® lawmaking +99417 when billing Medicare for prolonged office/outpatient Due east/M services:

+G2212

Prolonged part or other outpatient evaluation and management service(s) beyond the maximum required fourth dimension of the main procedure which has been selected using full time on the date of the primary service; each additional 15 minutes by the md or qualified healthcare professional, with or without direct patient contact (list separately in improver to cpt codes 99205, 99215 for office or other outpatient evaluation and management services) (practice not report g2212 on the same date of service every bit 99354, 99355, 99358, 99359, 99415, 99416). (exercise not report g2212 for whatsoever time unit less than 15 minutes)

The chief departure between the two codes is that +99417 applies to prolonged services fifteen minutes beyond the minimum required time and +G2212 applies to prolonged services fifteen minutes beyond the maximum required fourth dimension.

The MPFS 2021 final rule explained Medicare'south position that allowing +99417 for 15 minutes beyond the minimum time, instead of the maximum, results in "double counting" fourth dimension. The MPFS provides this example: 99215 has a time range of forty-54 minutes. If the provider reports prolonged services at 55 minutes, then 14 of those "prolonged" minutes are likewise captured in 99215. The AMA argued against Medicare's reasoning when commenting on MPFS 2021, just Medicare finalized +G2212 and requires that code for Medicare claims. Healthcare organizations should confirm with other payers which prolonged services code they take and which rules they apply.

Medicare-Specific HCPCS Lawmaking for Visit Complexity

The 2019 MPFS final dominion included a plan to create two new Thousand codes to represent the visit complication inherent to sure services, with ane code for designated specialists and a second lawmaking for primary care providers. The 2020 MPFS final rule inverse that, adopting a single new G code instead for use in 2021. The 2021 MPFS final rule inverse the descriptor slightly and confirmed the lawmaking would exist role of the 2021 HCPCS Level II lawmaking set:

+G2211

Visit complexity inherent to evaluation and direction associated with medical care services that serve as the continuing focal betoken for all needed wellness care services and/or with medical care services that are office of ongoing care related to a patient'due south single, serious condition or a complex condition. (add-on code, list separately in improver to function/outpatient evaluation and management visit, new or established)

The MPFS 2021 terminal rule indicated Medicare would reimburse providers for this code, merely Dec 2020 legislation related to COVID-19 relief changed this past including a moratorium on payment for G2211 until at least January 2024. This delay besides allows additional time for Medicare to clarify proper use of this code.

RVUs for 2021 Office/Outpatient E/M Codes

E/M visits comprise approximately forty% of allowed charges for MPFS services, and office/outpatient E/M visits comprise approximately 20% of allowed charges, the MPFS 2021 terminal rule states. As a outcome, pricing of these codes is an important subject, both for providers and for Medicare.

Fees on the MPFS are calculated using piece of work relative value units (RVUs), malpractice RVUs, and exercise expense RVUs multiplied by a conversion factor and adjusted based on geographic location. Additional factors such as other services reported for the patient, modifiers, and the patient's financial responsibility likewise can affect how much a provider receives from Medicare.

Tabular array 5 shows the first-quarter 2021 and 4th-quarter 2020 total RVUs for 99202-99215 (the MPFS is updated quarterly). The tabular array also includes the 2021 RVUs for new prolonged services lawmaking +G2212. MPFS facility RVUs are often lower than not-facility (office) RVUs considering when a physician provides services in a facility, the md is responsible for fewer exercise expenses. Remember that the final reimbursement amounts for E/G services will depend on more than just these RVUs.

Table v: Full RVUs for Office/Outpatient E/One thousand Codes

Code	2020 Q4 RVUs		2021 Q1 RVUs
	Not-Facility	Facility	Non-Facility	Facility
99202	2.14	1.43	2.13	1.42
99203	iii.03	2.14	3.28	two.42
99204	four.63	3.66	4.93	three.96
99205	v.85	iv.78	6.51	5.38
99211	0.65	0.26	0.68	0.27
99212	1.28	0.73	1.67	one.06
99213	2.xi	1.45	2.68	1.95
99214	3.06	2.23	three.81	two.88
99215	4.xi	iii.xv	five.33	4.27
+G2212	NA	NA	0.97	0.93

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Source: https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx

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