Almost all family physician practices use evaluation and management (E/M) codes. By knowing how to properly document and code for E/M services, family physicians and other qualified health professionals (QHPs), such as nurse practitioners and physician assistants, can maximize payment and reduce the stress of audits.
Generally, E/M services must be billed using Current Procedural Terminology (CPT) codes. There are different levels of E/M codes based on the complexity of the visit and the documentation required.
Due to Congressional action, the Primary Care Add-on Code G2211 was not implemented on January 1, 2021. All other anticipated payment, coding and documentation changes for 2021 are expected to go into effect.
NEW: 2021 Employed Physician Compensation Updates
The Medicare physician fee schedule for 2021 includes evaluation and management (E/M) increases, but many health systems do not implement them. By continuing to pay employed physicians at pre-2021 levels, meaningful investments in primary care will not be shared with them. To assist you in advocating for fair compensation with your employers, the Academy developed a member-only letter template with input from its Commission on Quality and Practice.
The changes will take effect in 2021
In response to advocacy from medical specialty societies, the CPT Editorial Panel revised the E/M documentation and coding guidelines for office visits as of January 1, 2021. These changes are meant to reduce paperwork and allow physicians more time with patients. CMS accepted these revisions and increased the relative values for office visit E/M codes, as well as adding a primary care add-on code to the Medicare physician fee schedule.
Highlights of key changes are as follows:
A patient’s history and physical exam are no longer components of selecting E/M level codes (when not appropriate). Physicians should still document the patient’s history and physical exam as medically appropriate. These elements may still be required for clinical practice, professional liability (i.e., malpractice), or quality measurement.
Code 99201 is no longer valid: CPT code 99201 has been deleted and is no longer available.
The 1995 and 1997 E/M documentation guidelines are no longer applicable to office visit codes. Instead, physicians must now decide between using total time or medical decision-making (MDM) to choose the level of office visit. It should be noted that the definition of total time in CPT office visit code selection has been broadened to include any time spent by the physician or qualified health professional – both face-to-face and non-face-to-face – in caring for the patient on the day of the encounter. Additionally, the elements of MDM have been revised. Further information is provided below regarding selecting E/M codes with either total time or MDM.
It is important to note that these changes only apply to office visits and outpatient E/M services (CPT codes 99202-99205 and 99211-99215).
Selecting E/M Codes by Total Time
Total time can be used to decide which code level to utilize for office-based E/M procedures (99202-99205 and 99212-99215). A noteworthy change in the new standards is the altered definition of time. It includes time spent by the doctor or other qualified health professional face-to-face or otherwise to look after the patient on the same day, including activities such as:
- Getting ready to see the patient (e.g., reviewing test results);
- Obtaining and/or reviewing separately obtained histories;
- Medication, tests, or procedures ordered;
- The electronic health record (EHR) or other records should be used to document clinical information;
- Interacting with the patient, family, and/or caregivers.
The time that would typically be devoted by clinical personnel (for instance, a nurse recording a patient’s history) should not factor into total time. In the same way, any activities on a date other than the date of service should get no consideration when selecting the service level for the encounter. Additionally, services that are accounted for separately (like independent interpretation and reporting of test results and tobacco cessation counseling) must not be part of total time computations.
Physicians need to ensure that the total time spent on the date of the encounter is documented in the patient’s medical record. Each code now has a specific time range. Instead of documenting time ranges, physicians should document specific total time spent on activities on the date of the encounter.
| CPT Code | Time Range |
|---|---|
| 99202 | 15-29 minutes |
| 99203 | 30-44 minutes |
| 99204 | 45-59 minutes |
| 99205 | 60-74 minutes |
| 99212 | 10-19 minutes |
| 99213 | 20-29 minutes |
| 99214 | 30-39 minutes |
| 99215 | 40-54 minutes |
Prolonged Services
Under CPT guidelines, when total time for a date of service exceeds the minimum period associated with the maximum level of service (e.g., 99205 or 99215) by 15 minutes or more, physicians may bill for prolonged services using the new add-on code 99417. This code covers “prolonged office or other outpatient evaluation and management service(s)… that require total time with or without direct patient contact beyond what is typical on the day of primary service,” with each 15 minutes billed separately. It is important to note that CPT code 99417 can only be applied when total time is used to determine the level of service, and should not be billed for intervals less than 15 minutes. Furthermore, it cannot be applied in conjunction with any of the following codes: 99354, 99355, 99358, 99359, 99415 or 99416.
CMS doesn’t cover CPT code 99417 in cases of prolonged services. Instead, a practitioner should use HCPCS code G2212 to bill Medicare patients when they spend longer than the maximum required time for the primary procedure on the chosen date of service. Note that G2212 isn’t applicable for increments less than 15 minutes. Also, it shouldn’t be used for CPT codes 99354, 99355, 99358, 99359, 99415 or 99416.
Selecting E/M Codes by MDM
MDM is the reflection of complexity, depicting the cognitive function required to arrive at a diagnosis, assess the status of a condition, and select a management option. The updated MDM table has been revised to emphasize the thought processes that guide medical professionals in diagnosing and caring for their patients – such as therapies considered but not chosen. To qualify for a certain level of MDM, two of the three elements must meet or exceed expectations.
Problems addressed at the meeting and their complexity
There was no consideration of the complexity of the patient’s condition in the 1995/1997 MDM elements based on the number of diagnoses. Instead of just counting the number of diagnoses, the revised MDM table takes into account the complexity of the problems addressed. Physicians should not select a level of MDM based on diagnoses made or addressed during the encounter and that do not contribute to the physician’s MDM process.
The amount and/or complexity of the data to be reviewed and analyzed
A physician should include labs and tests that were relevant to the encounter and contributed to the MDM for it. Labs/tests are defined by their corresponding CPT codes, so a panel would be considered one lab for these purposes. Data that does not impact the assessment and treatment of the patient should not be copied into the note.
Complications and/or morbidity and mortality associated with patient management
Complications and/or morbidity and mortality related to patient management are caused by a variety of factors. Examples include, but are not limited to, prescription management, social determinants of health, and surgical decisions. When determining the risk, options considered but not selected should be documented appropriately.
| CPT Codes | Levels of MDM | Number and complexity of problems addressed | Amount and/or complexity of data to be reviewed and analyzed | Risk of complications and/or morbidity or mortality |
|---|---|---|---|---|
| 99202, 99212 | Straightforward | Minimal | Minimal or None | Minimal |
| 99203, 99213 | Low | Low | Limited | Low |
| 99204, 99214 | Moderate | Moderate | Moderate | Moderate |
| 99205, 99215 | High | High | Extensive | High |
Primary Care Add-on Code (G2211)
It has been determined that the Primary Care Add-on Code G2211 will not be implemented on January 1, 2021, as expected due to Congressional action. All other anticipated payment, coding, and documentation changes for 2021 will go into effect as scheduled.
Values increased
Using the Medicare Physician Fee Schedule Lookup Tool, physicians can look up the new values and allowed amounts for office visit E/M codes.
Payers in the private sector
These coding and documentation guidelines are applicable to both Medicare and private payers. Although the primary care add-on code may not be accepted universally, physicians should work with their provider relations representatives to ensure these enhanced values can be included into their contract. The “Questions to Ask Your Payers” resource listed below can provide a useful point of reference for this conversation.
