nt E&M Services (CPT codes 99202-99215) 2021 EM... · 2020. 12. 24. · 5 AQ’s & 'uidance:...

Vers. 3-29-21 (replaces 12-23-20) 1

FAQ’s & Guidance: Outpatient E&M Services (CPT codes 99202-99215)

:::::::::EFFECTIVE JANUARY 1, 2021

Table of Contents

E/M Code Selection Differences

Required Elements for New vs. Est Outpatients (99202-99215)

Counting Teaching Physician Time w/ Housestaff

FAQs - Attestations

- History & Exam

- Interactive

Complexity

FAQs - Leveling by MDM - Leveling by Time - LOS calculator - Prolonged Services

Contact Us

Summary of E/M Code Selection Differences

Office or Other Outpatient Services (99202-99215) NEW Other E/M Services (Consults, Observation, Inpatient, ED)

History & Exam As medically appropriate (not used in code selection) Use 3 key components (History, Exam, MDM)

MDM May use MDM to level service OR Use 3 key components (History, Exam, MDM)

Time May use total time spent on the date of the encounter (F2F and non-F2F time)

May use face-to-face time (or time at bedside/on unit) when counseling and/or coordination of care dominate > 50% of the service (Concept n/a for ED)

MDM Elements

• Number and complexity of problems addressed at the encounter • Amount and/or complexity of data to be reviewed and analyzed • Risk of complications and/or morbidity or mortality of patient mgmt

• Number and diagnoses or management options • Amount and/or complexity of data to be reviewed • Risk of complications and/or morbidity or mortality

Required Elements for New vs. Established Patients (99202-99215)

Counting Teaching Physician Time with Housestaff (Residents & Fellows) UPDATED 3-29-21

CPT History & Exam MDM Time History & Exam MDM Time

99201 Deleted Deleted Deleted 99211 N/A N/A N/A

99202 Straightfwd 15-29 min 99212 Straightfwd 10-19 min

99203 Low 30-44 min 99213 Low 20-29 min

99204 Moderate 45-59 min 99214 Moderate 30-39 min

99205 High 60-74 min 99215 High 40-54 min

Medically Appropriate

History and/or Exam

ESTABLISHED PATIENTS Required Elements (99211-99215)

Medically Appropriate

History and/or Exam

99211: for use in physician offices (POS 11) where medical staff see return

patients F2F with physician supervision

NEW PATIENTS Required Elements (99202-99205)

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History & Exam FAQ’s

1. Will there be guidelines that outline what a medically appropriate exam is?

At this time, none are expected from insurers or AMA. It is up to the provider to determine the nature and extent of

the exam required to support the medical necessity of the service. For example, if a patient presents with shoulder

bursitis, it is not required that you talk about a headache or document a pulmonary exam for the purpose of leveling

history and exam. While the provider has the choice to capture as little or as much as they feel is appropriate, it is

important that the note describes how the exam impacted the patient care decisions made by the provider.

2. Does a chief complaint have to be documented? UPDATED 3-29-21

Yes, a chief complaint still needs to be documented to support why the patient needed to seek a practitioner’s care. It

may be collected by another member of the care team, such as an M.A. or R.N. Document the review of any

information obtained.

3. What if my care team collects history and exam information, including chief complaints?

If history and exam elements are collected by members of the care team you must document in the medical record

that you reviewed the information.

4. Do we have to document a Review of Systems (ROS) for new and return patients?

Only if you feel it is medically appropriate and relevant to the patient’s condition and visit to conduct and document an

ROS. This may still be relevant to a variety of presenting problems.

5. Is a history and exam still required for outpatient and inpatient Consultations (99241-99245, 99251-99255)? UPDATED 3-29-21

Yes. Consults still require History, Exam, and MDM to match the level of consult you are billing. All three components

will still be needed for consults. You may use the EPIC Level of Service calculator to assist you in leveling Consultations

or Outpatient Office E/M (99202-99215) using the appropriate criteria. To do this, change the “Service Type” in the

right upper hand corner of the calculator.

6. What do we need to consider about copying and pasting with the new updates to history and exam?

History & Exam will no longer be used as elements to level an Outpatient E/M visit. To avoid note bloat and the

inclusion of large amounts of data that are not relevant to the visit or treatment that day, copying and pasting all

previous notes are discouraged. If notes are setup to carry forward certain items, be sure to actively address or update

items and remove those that don’t apply or have no updates.

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Time FAQ’s

7. What are the activities that may be counted in total time on the date of the encounter?

Both face-to-face and non-face-to-face time spent performing the below activities may be counted in total time as long

as it is spent on the Date of Service (same calendar date of the service).

preparing to see the patient (eg, review of tests or documents prior to visit)

obtaining and/or reviewing separately obtained history (i.e. that obtained by MA or RN, etc)

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)

8. What type of time/activities may NOT be included in total time? UPDATED 3-29-21

Exclude time spent on the following:

o time spent on separately reportable services that will be billed by the provider.

o time spent by clinical staff such as that of an MA or RN or other facility employed staff

o time spent on travel (i.e. to a home health visit)

o time spent teaching (i.e. on general teaching concepts)

9. May time spent on involvement with prior authorizations with insurance companies be considered as care

coordination?

No, prior authorization activity may not be counted at this time. Clinical coordination involves determining where to

send the patient next (e.g., sequencing among specialists), what information about the patient is necessary to transfer

among health care entities, and how accountability and responsibility is managed among all health care professionals

(doctors, nurses, social workers, care managers, supporting staff, etc.). AHRQ.gov

10. May time spent in tumor board be considered as discussion with other health care professionals?

Yes, discussion with tumor boards to assist with direct patient care may be counted. Keep in mind that tumor boards

are not typically on the date of encounter, so when leveling by time only count time spent on the date of encounter.

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11. Are we allowed to count the time pre-charting the day before?

No. Only face-to-face and non-face-to-face time spent on the date of service (calendar date of the encounter) may be

counted in total time.

12. Can we include the time house staff or the care team spend collecting history when working in our clinic?

No. Only the time of the billing practitioner may be counted. However, the time spent by the Teaching Physician

reviewing any separately obtained history may be counted.

13. When leveling by time do we still have to meet the > 50% requirement for counseling and/or coordination of care?

No, this rule no longer applies to Office & Other Outpatient Visits (99202-99215). It still applies to Consultations,

Observation, and Inpatient services. See the chart on page 1 for leveling differences.

14. May I count Housestaff time when leveling my service? UPDATED 3-29-21

If you are a Teaching Physician in a non-primary care exception area you may not use any time spent by the housestaff

in leveling your service. Use solely the Teaching Physician time when leveling in a non-PCE area. Leveling by MDM is

also a choice.

If you are a Teaching Physician supervising housestaff in a Primary Care Exception (PCE) clinic, then the housestaff’s

time may be counted along with time spent by the Teaching Physician in seeing the patient and/or reviewing the plan

of care. The PCE housestaff should use .TIMEATTEST to document their time separately. Use the housestaff’s time

and/or Teaching Physician time when leveling by time in a PCE area. Leveling by MDM is also a choice.

15. May I count the time I spend discussing the patient with housestaff (residents & fellows)? UPDATED 3-29-21

The AMA recently clarified that time spent on general teaching may not be counted (i.e. time not spent on discussion

required for the management of a specific patient).

16. May I count time spent talking to the patient after a visit about results?

Yes, as long as it occurs on the same date of service the time may be counted toward your level of service.

17. May I count the time a social worker spends with a patient?

No, only count the time you spend with the patient. Only billing practitioner time is counted.

18. If a social worker is meeting with the patient, but the billing practitioner is also present can that time be counted?

Yes, if the billing practitioner is also present with the social work for purposes of patient care or coordination that time

may be counted.

19. If I perform an E/M and also do psychotherapy (timed code), may I also use time to level my E/M?

No, when performing both an E/M service and psychotherapy service, you may not use time to level the E/M service.

Please use MDM.

20. Do phone calls on the DOS count towards time?

Per NGS phone calls on the date of service with the patient to get more information, or calls with another physician or

independent historian, could be counted as time spent on the DOS as long as the activity is related to (or informs) the

clinical decision making for the service.

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21. If leveling a split-shared visit by Time, what is the appropriate way to count time?

Distinct non-overlapping time personally spent by the Physician and NPP (APN/PA) on the date of encounter may be

summed. If the Physician & NPP jointly meet with the patient, or discuss the patient – only the time of one individual

should be counted. As a reminder, whomever bills for the split-shared visit must have had F2F time with the patient.

Note that the split-shared concept does not apply to consultations, procedures, or critical care.

Medical Decision Making (MDM) FAQ’s

There is a new MDM table solely to be used for outpatient visits (99202-99215). For step by step instructions on selecting the

level of MDM see Outpatient E/M Tip Sheet, alternatively you may use the EPIC Outpatient LOS Calculator.

Below are FAQ’s for each of the 3 Elements of MDM:

Element 1: Number and Complexity of Problems Addressed at the Encounter

22. When is a problem considered addressed per the chart above?

A problem is addressed or managed when it is evaluated or treated at the encounter by the billing practitioner

reporting the service. Keep in mind the acronym M.E.A.T. (Managed, Evaluated, Assessed, or Treated).

Addressing a problem includes consideration of further testing or treatment that may not be elected by virtue of

risk/benefit analysis or patient/parent/guardian/surrogate choice.

23. What types of problems may NOT be considered as a problem addressed?

The below scenarios may not be considered as problems addressed:

Noting that another professional is managing the problem (without additional assessment or care

coordination)

Referring a patient without evaluation or consideration of treatment

Presence of comorbidities alone unless they are addressed and their presence increases a) the amount and/or

complexity of data reviewed and analyzed or b) the risk of complications and/or morbidity of patient

management

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https://compliance.bsd.uchicago.edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdf

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24. What is a minimal problem?

It is a problem that may not require the presence of a physician, but is provided under the physician or other health

care professional’s supervision (see 99211). AMA

25. When is a chronic illness considered stable?

Per AMA “stable” for the purposes of categorizing medical decision making is defined by the specific treatment goals

for an individual patient. A patient that is not at their treatment goal is not stable, even if the condition has not

changed and there is no short term threat to life or function.

26. When would a problem be considered as an undiagnosed new problem with uncertain prognosis?

Per AMA, this is a problem in the differential diagnosis that represents a condition likely to result in a high risk of

morbidity without treatment. An example may be a lump in the breast. Another example may be significant dyspnea

on exertion that is not described by a cold for example (could this patient have heart failure), or a patient with

hematuria which could be either a UTI, kidney stone, or renal carcinoma.

27. Where do I find definitions for the various problems addressed in this section?

You may find a full glossary of terms in our Outpatient E/M Tip Sheet.

Element 2: Amount and/or Complexity of Data to be Reviewed and Analyzed

28. What is considered a unique test for the purposes of counting the reviewing or ordering of each unique test? UPDATED 3-29-21

Each unique test is counted as 1 test in the MDM table. The test must be a unique/different test, i.e. Lipid Panel, CBC,

and TSH are three unique tests. Ordering of each unique test includes review of the result and is counted only in that

encounter. For example, do not count the review of the results at a subsequent encounter.

29. Do translation services or translators count as independent historian?

No, it does not because the history is still coming from the patient, it is just being translated. An independent historian

is an individual who provides a history in addition to a history provide by a patient who is unable to provide a complete

or reliable history (due to developmental stage, dementia, or psychosis).

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https://compliance.bsd.uchicago.edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdf

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30. For pediatric providers, can the child’s history obtained from the parent be counted as an assessment requiring

independent historian?

Yes, as confirmed by NGS.

31. May I count independent interpretation of a test when I personally am performing and billing the service?

No, do not count tests in MDM that you are performing or interpreting that you plan to bill separately for.

32. What are documentation requirements for independent interpretation of a test?

When a provider performs an independent interpretation of a test they ordered, some form of interpretation should

be documented, but it doesn’t need to normal reporting standards. When including an interpretation in MDM, it must

be a test for which there is a CPT code, and an interpretation or report is customary.

33. How do you count a panel test such as BMP for the purpose of counting number of tests ordered?

A clinical laboratory panel such as BMP (80047) is considered as a single test.

34. If you order a CBC now and a CBC to be done 6 months from now – is that two orders?

No, it is not counted as two orders since both are a CBC and not two different “unique” tests.

35. When you order a test, can you also count the review of that test?

No, when you order a test, the review of that test is included; it is not counted separately. For instance, you order a

strep test and review the results the same or next day; count only the order of the test. Note that the review of the

test result is part of the encounter and not a subsequent encounter. For instance, you would not save the review to

count on a subsequent visit.

36. Considering the example above, when would you count the review of a test?

You may count each unique document that is reviewed or analyzed such as discharge summaries, psychometric testing

or an echocardiogram. Ensure that these items are not simply cut and paste into the record, and that they are relevant

to the care of the patient. Note the review or analysis relevant to your medical decision making in the documentation.

37. Who is considered an external provider for the purposes of discussion of management or test interpretation?

An external physician or other qualified health care professional is an individual who is not in the same group practice

or is in a different specialty or subspecialty (including APN’s/PA’s). An external provider would not be an RN or Social

Worker that is on your care team.

38. Who is considered an external appropriate source for the purposes of discussion of management or test

interpretation?

An external facility or organizational provider such as a hospital, nursing facility, or home health care agency.

39. Does discussion of management with external providers have to be on the same day as the visit? UPDATED 3-29-21

Discussion does not need to be on the date of the encounter, but it is counted only once and only when using in

decision making of the encounter. It must also be initiated and completed within a short time frame (within a day or

two).

40. Does discussion of management or test interpretation that I do with the patient count for MDM?

No, you may not count such discussions with patients in your MDM.

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41. What can be considered discussion of management or test interpretation with external physician? NEW 3-29-21

Discussion requires a direct exchange, so the following may not be counted in MDM:

Discussion through intermediaries (such as clinical staff or trainees)

Sending charts notes

Sending written exchanges in progress notes

42. Does cutting and pasting a result into the note, such as a CT report count as a test result that was reviewed?

No, simply cutting and pasting a result into the note with no mention of your review and/or analysis cannot be

counted as a review for the purposes of MDM.

43. Do you get credit for a test you order but are going to bill for? UPDATED 3-29-21

No, do not count this as a test you ordered since you will be billing separately for the performance and/or

interpretation of the service. The ordering and actual performance and/or interpretation of diagnostic tests/studies

during a patient encounter are not included in determining the levels of E/M services when reported separately by the

professional reporting the E/M service (AMA).

44. What if a test is ordered by a physician in my specialty, but I review it?

AMA considers physicians in the same specialty as one provider (the same provider). Do not count reviews of tests

ordered by someone in your specialty/group.

45. Can I get credit for independently interpreting standard lab results that someone else ordered? NEW 3-29-21

No, tests that do not require separate interpretation (i.e. tests that are results only) do not count as independent

interpretation.

Element 3: Risk of Complications and/or Morbidity or Mortality of Patient Management Decisions

46. How should risk be considered in relation to patient management decisions? UPDATED 3-29-21

Consider the risk of morbidity/mortality associated with treatment decisions the provider has to make at the visit

which are associated with the patient’s problems, diagnostic procedures, treatments. This risk is distinct from the risk

of the condition itself.

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47. The MDM table considers risk associated with minor and major surgery. What exactly does “surgery risk factor,

patient or procedure” mean? NEW 3-29-21

AMA has defined risk factors as those that are relevant to the patient and procedure. Evidence-based risk calculators

may be used, but are not required, in assessing patient and procedure risk.

AMA also clarifies that the classification of surgery into minor or major is based on the common meaning of the term

when used by trained clinicians. It is not defined by the global surgical package classification.

48. What if I consider a treatment option, but do not ultimately select it?

Treatment options considered, but ruled after shared decision making with the patient/family may be included in

MDM. For example, a provider may decide not to hospitalize a patient for whom the goal is palliative treatment. Be

sure to document such decisions.

49. In the table, OTC drugs are stated as low risk. What if my patient has conditions or long term medications that raise

risk?

Risks will ultimately be based on factors unique to the patient. Some of the examples in the table above could end up

in different category due to a patient’s clinical situation as determined by the provider.

50. Do minor and major surgeries align directly with the global period of a surgery?

Though the global period of a surgery is a good way to conceptualize or understand when something may be

considered a minor (0, 10) or major surgery (90), the determination of minor or major surgery with or without risk

factors will be determined by the physician. Also consider that the global period concept will be phasing out over the

next few years.

51. Social determinants of health (SDOH) is listed as a Moderate risk, what exactly does SDOH mean with regards to risk

treating the patient?

Economic and social conditions that influence the health of people and communities (AMA). Examples may include

food or housing insecurity that may significantly limit diagnosing or treating the patient. Please review the Outpatient

E/M Tip Sheet for more specific examples.

52. When should SDOH be considered in the risk for a particular visit?

If factoring SDOH into the MDM, documentation should be clear (i.e. patient noncompliant can’t afford xyz medication

to treat arrhythmia, or patient does not have a place to wash wound 3x a day to prevent infection). Considering SDOH

should relate to decision making relevant to what the provider is doing that day.

Prolonged Services

53. How is the new Prolonged Service add-on code 99417 used in conjunction with Office Outpatient E/M visits?

CPT 99417 can be used as an add-on solely with levels 99205 & 99215, and only when the original service is leveled

using time. The code represents each 15 minutes of additional time beyond the CPT maximum. CPT 99417 includes

both direct and indirect time, but is only for time spent solely on the Date of Service. Please note that Medicare will

only accept a substitute HCPCS code, G2212 instead of 99417.

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https://compliance.bsd.uchicago.edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdfhttps://compliance.bsd.uchicago.edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdf

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54. When may one start using the add-on code if all requirements have been met?

For new patients 99205 when leveling by time, to bill one unit of CPT 99417 you must have spent at least 89 minutes

which is 15 minutes beyond the maximum time of 74 minutes for the E/M.

For established patients 99215 when leveling by time, to bill one unit of CPT 99417 you must have spent at least 69

minutes which is 15 minutes beyond the maximum time of 54 minutes for the E/M.

55. Can we still use Prolonged Service codes like 99358 & 99359 for non-face-to-face time spent on another date of

service?

CPT codes 99358 & 99359 are still active in the CPT book for use in conjunction with 99202-99215 for prolonged non-

face-to-face time on another date of service. However, CMS will no longer pay for this service in conjunction with

99202-99215 for Medicare beneficiaries.

Interactive Complexity

G2211: “Visit complexity inherent to E/M associated with medical care services that serve as the continuing focal point for all needed health care services

and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex condition. Add-on code, list separately in

addition to office/outpatient E/M visit, new or established)

56. How is the new Visit Complexity add-on code for Medicare patients used?

Interactive Visit Complexity G2211 represents visit complexity related to a patient’s single complex medical condition

and recognizes the resources involved in providing ongoing care needs and evolving illness. It is intended for primary

care and certain types of specialty visits.

57. What are some examples of how Interactive Visit Complexity add-on code for Medicare patients be used?

In primary care, G2211 could recognize the resources in inherent in holistic, patient-centered care that integrates the

treatment of illness or injury, management of acute and chronic health conditions, and coordination of specialty care

in a collaborate relationship with the clinical care team.

In specialty care, G2211 could recognize the resources inherent in engaging the patient in a continuous and active

collaborative plan of care related to an identified health condition the management of which requires the direction of

a clinician with specialized clinical knowledge, skill and experience. Such collaborate care includes patient education,

expectations and responsibilities, shared decision-making around therapeutic goals, and shared commitments to

achieve those goals.

58. When would using the new Interactive Visit Complexity add-on code NOT be appropriate?

It would not be appropriate to bill Medicare (and the beneficiary) for G2211 when the relationship with the patient is

of a discrete, routine or time limited nature. Below are some examples: Mole removal or referral to a physician for removal of a mole

Treatment of a simple virus

Counseling related to seasonal allergies

Initial onset gastroesophageal reflux disease

Treatment for a fracture

Where comorbidities are either not present or not addressed,

When the billing practitioner has not taken responsibility for ongoing medical care for that patient with consistency an

continuity over time, or does not plan to take such responsibility.

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CMS also does not expect that G2211 would be reported when the office/outpatient E/M is reported with a payment

modifier such as modifier -25. BACK TO TOP

59. Will other payors recognize G2211? UPDATED 3-29-21

Medicare recently announced that G2211 will be considered a bundled service, which means that no separate

payment will be received when G2211 is reported. At this time, it is unclear if other payors will recognize and/or pay

for Interactive Visit Complexity services.

Attestation Statements

The below existing attestation statements have been optimized to accommodate provider leveling choices for Outpatient

E/M in 2021:

Teaching Physician alone: .ATTESTNOTPRESENTAMB

Teaching Physician with Housestaff (non PCE): .ATTESTPRESENTAMB

Teaching Physician - PCE: .ATTESTPRIMARYCAREEXCEPTION

Attending Supervising Medical Student: .ATTESTMEDSTAMB

Resident Supervising Medical Student: .RESSTUDENTATTESTAMB

PA/NP Supervises student: .ATTEST_PA/APNSTUDENT-AMB

60. How do I use the above attestation statements to document time? UPDATED 3-29-21

Within the attestation statement, you will be able to use a smartlist phrase to capture time. If you do not intend to

level by time, then you do not need to fill it out. When the statement is ignored, the time smartphrase will disappear.

61. How do I use the attestation statements above when leveling by MDM?

Be sure to document the Risk level of your patient (Patient Complexity), which will help support the MDM level along

with documentation in your note. When leveling by MDM, you may remove the smartlist phrase concerning time.

62. What does an Attending or APP use when they are not supervising a resident or student?

An Attending or APP (APN or PA) may use the Ambulatory General Progress Note template to document time. If time is

not a factor in leveling the service, the statement can be deleted from the template. If leveling by MDM, please include

a statement of the patient’s level of risk (Low, Moderate, High, Extensive) somewhere within the note. Note that the

level of risk alone does not determine the final MDM level.

63. How can a Resident in a PCE setting document the time they spent face-to-face with a patient?

The Ambulatory General Progress Note template may be used to document time. If time is not a factor, the statement

can be deleted from the template. If leveling by MDM, the patients level of risk (Low, Moderate, High, Extensive) may

alternatively be noted. Note that the level of risk alone does not determine the final MDM level.

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Outpatient LOS Calculator

64. How do I access the LOS Calculator to assist with leveling by MDM or Time?

In the Wrap-Up Tab, click on LOS. In the Level of Service section, select the wand.

65. Can I change the Outpatient LOS calculator to help level Outpatient Consultations?

The LOS calculator is defaulted to Outpatient or Consultation Service Type depending on how the visit was scheduled.

If your service was not scheduled as a consultation, you can manually change the Service Type drop down in the

calculator to an Outpatient Consultation (see highlighted box).

Contact Us

Office of Corporate Compliance website:

Find the step-by-step Outpatient E/M Tip Sheet and other E/M resources HERE under 2021 Outpatient E/M

For additional Outpatient E/M questions, submit to [email protected]

Contact the Office of Corporate Compliance directly at 773-834-4733

To report concerns related to suspected non-compliance, fraud, waste or abuse: 877-440-5480 or 833-484-0045 (Ingalls/PHA)

https://compliance.bsd.uchicago.edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdfhttps://compliance.bsd.uchicago.edu/faculty_staff_page.html#tabbed-nav=polmailto:[email protected]

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