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INTRODUCTION TO 2021 OFFICE AND

OTHER OUTPATIENT E/M CODES

EFFECTIVE DATE: JANUARY 1, 2021

BENJAMIN N. SHAIN, MD, PHD

AACAP COMMITTEE ON CODING AND REIMBURSEMENT

CPT is a registered trademark of the American Medical Association. Copyright 2020 American

Medical Association. All rights reserved.

QUESTIONS?

• Please contact Karen Ferguson at [email protected] or 202-587-9670.

• Karen is our Committee staff person and will either answer your questions or pass them on to the Committee.

mailto:[email protected]

AGENDA

• Structure of E/M codes• Coding based on time• Prolonged service• Coding based on medical decision making (MDM)

STRUCTURE OF E/M CODES

• Most E/M codes are part of a ”family”• Site of service, for

example:• Office and other

outpatient• Inpatient• Nursing facility• Emergency department

• Patient status, for example:• New• Established• Day of discharge• Consultation

LEVELS

• Most code families have multiple levels• Typically 3 or 5 levels• Level is denoted by the 5th digit of the code

THE SUBJECT OF THIS WEBINAR

• Only 3 code families will be discussed• Office and other outpatient service, new patient• Office and other outpatient service, established patient• Prolonged service

• None of the other code families have changed, although are likely to do so in the next several years

UNCHANGED FAMILIES

• Hospital inpatient services (including physician services for patients in PHP and IOP)• Initial hospital care• Subsequent hospital care• Hospital discharge services

• Consultation• Office or other outpatient• Inpatient

SELECTING THE E/M CODE FAMILY – NEW OR ESTABLISHED PATIENT

• A new patient • No professional services from the physician/qualified health care

professional in the last 3 years• OR from another physician/qualified health care professional

• Exact same specialty AND subspecialty who belongs to the same group practice

• On call or covering • Classified as it would have been by the physician/qualified health

care professional who is not available• Advanced practice nurses and physician assistants working

with physicians• Exact same specialty and exact same subspecialties as the

physician

SELECTING THE E/M CODE LEVEL

• Total time, or• Medical decision making (MDM)• Choice is strictly the option of the physician or

other qualified health care professional• When psychotherapy add-on code is reported -

E/M code may NOT be selected based on time

WHAT DOES NOT MATTER IN SELECTING THE CODE LEVEL

• Extent of history and/or physical examination• Services include a medically appropriate history and/or

physical examination

• Determined by the treating physician based on the situation and what is clinically indicated

• The care team may collect information and the patient or caregiver may supply information

WHAT DOES NOT MATTER IN SELECTING THE CODE LEVEL

• Extent of counseling and/or coordination of care• Comorbidities/underlying diseases, in and of

themselves, are not considered in selecting a level of E/M services

• Services that are reported using a separate CPT code

USING TIME TO SELECT THE CODE LEVEL

• Time is the total time on the date of the encounter

• Includes both the face-to-face and non-face-to-face time personally spent on the day of the encounter • Includes time in activities that require the physician or

other qualified health care professional

• Does not include time in activities normally performed by clinical staff

WHEN THE VISIT IS SHARED OR SPLIT

• A shared or split visit is defined as a visit in which physicians and/or other qualified healthcare professionals jointly provide the face-to-face and non-face-to-face work related to the visit. • Time personally spent is summed to define total time. • CPT does not address time spent by trainees

• Only distinct time should be summed• i.e., when two or more individuals jointly meet with or

discuss the patient, only the time of one individual should be counted

TOTAL TIME INCLUDES THESE ACTIVITIES• Preparing to see the

patient (eg, 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

• This is NOT psychotherapy!

• Ordering medications, tests, or procedures

• Referring and communicating with other health care professionals

• 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

WHEN USING TIME FOR CODE SELECTION

• 99202 – 15-29 min• 99203 – 30-44 min• 99204 – 45-59 min• 99205 – 60-74 min

• 99211 – not reported by time

• 99212 – 10-19 min• 99213 – 20-29 min• 99214 – 30-39 min• 99215 – 40-54 min

WHEN USING TIME FOR CODE SELECTION

• 99202 – 15 min• 99203 – 30 min• 99204 – 45 min• 99205 – 60 min

• 99211 – not reported by time

• 99212 – 10 min• 99213 – 20 min• 99214 – 30 min• 99215 – 40 min

PROLONGED SERVICE (99417)

• Prolonged total time on the date of office or other outpatient services

• 15-minute increments after the total time of the highest-level service (ie, 99205 or 99215) has been exceeded

• Only use when the office or other outpatient service has been selected using time alone as the basis


• To report a unit of 99417, 15 minutes of additional time must have been attained.

• Do not report 99417 for any additional time increment of less than 15 minutes.

EXAMPLE

• Total time for established patient = 75 min• 99215 (40 min)• + 2 units 99417 (15 min each = 30 min)• Last 5 min – not reportable


• Prolonged office or other outpatient evaluation and management service(s) beyond the total time for 99205 (60 minutes) or 99215 (40 minutes); each 15 minutes

TIMELINE FOR NEW PATIENT CODES

Total time (min)

TIMELINE FOR ESTABLISHED PATIENT CODES

Total time (min)

USING MEDICAL DECISION MAKING (MDM) FOR CODE SELECTION

• MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option

MDM IS DEFINED BY THREE ELEMENTS

1. The number and complexity of problem(s) that are addressed during the encounter


2. The amount and/or complexity of data to be reviewed and analyzed. • Tests, documents, orders, or independent

historian(s)

• Independent interpretation of tests• Discussion with external physician or other

qualified healthcare professional or an appropriate source


3. Risk related to management decisions made at the visit• This includes the possible management options

selected and those considered, but not selected, after shared medical decision making.

• CPT examples:• A psychiatric patient with a sufficient degree of

support in the outpatient setting• The decision to not hospitalize a patient with

advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment.

MED

ICAL

DEC

ISIO

N M

AKIN

GElements of Medical Decision Making

Code

Level of MDM(based on best

of 2 out of 3 Elements of

MDM)Number and Complexity of

Problems Addressed

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

Risk of Complications and/or Morbidity or Mortality of Patient Management

(Includes options considered but not selected after shared medical decision making)

99211 N/A N/A N/A N/A

9920299212 Straightforward

Minimal

• 1 self-limited or minor problem

Minimal or none Minimal risk of morbidity from additional diagnostic testing or treatment

9920399213 Low

Low

• 2 or more self-limited or minor problems;• 1 stable chronic illness; or• 1 acute, uncomplicated illness

or injury

LimitedMust meet the requirements of at least 1 of the 2 categories• Category 1: Tests and documents - Any combination of 2 from the following:

• Review of prior external note(s) from each unique source*;• Review of the result(s) of each unique test*;• Ordering of each unique test*.

• Category 2: Assessment requiring an independent historian(s)

Low risk of morbidity from additional diagnostic testing or treatment

9920499214 Moderate

Moderate

• 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;• 2 or more stable chronic

illnesses;• 1 undiagnosed new problem

with uncertain prognosis;• 1 acute illness with systemic

symptoms; or• 1 acute complicated injury

ModerateMust meet the requirements of at least 1 of the 3 categories• Category 1: Tests and documents - Any combination of 3 from the following:

• Review of prior external note(s) from each unique source*;• Review of the result(s) of each unique test*;• Ordering of each unique test*;• Assessment requiring an independent historian(s).

• Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another

physician/other qualified health care professional (not separately reported).

• Category 3: Discussion of management or test interpretation• Discussion of management or test interpretation by external

physician/other qualified health care professional/appropriate source (not separately reported).

Moderate risk of morbidity from additional diagnostic testing or treatment

Examples only:• Prescription drug management• Decision regarding minor surgery with

identified patient or procedure risk factors• Decision regarding elective major surgery

without identified patient or procedure risk factors• Diagnosis or treatment significantly limited

by social determinants of health

9920599215 High

High

• 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or• 1 acute or chronic illness or

injury that poses a threat to life or bodily function

ExtensiveMust meet the requirements of at least 2 of the 3 categories• Category 1: Tests and documents - Any combination of 3 from the following:






High risk of morbidity from additional diagnostic testing or treatment

Examples only:• Drug therapy requiring intensive monitoring

for toxicity• Decision regarding elective major surgery

with identified patient or procedure risk factors• Decision regarding emergency major

surgery• Decision regarding hospitalization• Decision not to resuscitate or to de-escalate

care because of poor prognosis

Decision regarding minor surgery with identified patient or procedure risk factors

Decision not to resuscitate or to de-escalate care because of poor prognosis

Review of prior external note(s) from each unique source

Assessment requiring an independent historian(s)

DATA COLUMN NOT THAT USEFUL

• “Problems” is risk from the underlying illness• “Risk” is risk from selected or considered

management options• Typically risk from the illness and risk from the

management options run in lockstep• Usually not enough Data elements to get to the

next level• If lots of communicating to other providers, time

usually works

MED

ICAL

DEC

ISIO

N M

AKIN

G

Code

Level of MDM(based on both Problems and

Risk)

Elements of Medical Decision Making

Number and Complexity of Problems Addressed

Risk of Complications and/or Morbidity or Mortality from Patient Management


99211 N/A N/A N/A

9920299212

StraightforwardMinimal

• 1 self-limited or minor problemMinimal risk of morbidity from additional

diagnostic testing or treatment

9920399213

Low

Low• 2 or more self-limited or minor problems;• 1 stable chronic illness; or• 1 acute, uncomplicated illness or injury


9920499214

Moderate

Moderate• 1 or more chronic illnesses with exacerbation,

progression, or side effects of treatment;• 2 or more stable chronic illnesses;• 1 undiagnosed new problem with uncertain prognosis;• 1 acute illness with systemic symptoms; or• 1 acute complicated injury


Examples only:• Prescription drug management• Diagnosis or treatment significantly

limited by social determinants of health

9920599215

High

High

• 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or

• 1 acute or chronic illness or injury that poses a threat to life or bodily function


Examples only:• Drug therapy requiring intensive

monitoring for toxicity• Decision regarding hospitalization

PROBLEM DEFINITIONS

• Problem• A problem is a disease, condition, illness, injury,

symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter

PROBLEM ADDRESSED

• A problem is addressed or managed when it is evaluated or treated at the encounter• This includes consideration of further testing or

treatment that may or may not be elected

• Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’

• Referral without evaluation does not count as ‘addressed’