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

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

There have been many calls to simplify E/M coding over the years, but the 2019 Medicare Physician Fee Schedule (MPFS) rule is particularly helpful for understanding the background of the 2021 E/M updates.

The MPFS is funded by 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 final rule explaining changes planned for the next year’s MPFS.

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

One policy change in the 2019 MPFS final rule that got a large reaction from providers was a plan to pay a single rate, called a blended rate, for E/M visit levels 2 to 4 starting in 2021. In other words, Medicare intended to pay the same rate for new patient codes 99202, 99203, and 99204, regardless of which code was reported. Medicare was going to pay another single rate for established patient codes 99212, 99213, and 99214. Level-5 visits (99205, 99215) would have separate rates to reflect the increased complexity those codes represent.

Although this plan for blended rates was in the 2019 final rule, Medicare later stated this fee-structure change would not go through. The MPFS continues to list 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 plan. You will read more about those codes in the sections below.

The 2019 MPFS final rule also indicated Medicare would allow practitioners to document office and outpatient levels 2 to 5 using only MDM or time starting in 2021. Providers would be allowed to continue to use the 1995 and 1997 Documentation Guidelines as the basis for their coding if they preferred. However, as you will see, AMA’s 2021 E/M code revisions eliminate the need for use of the 1995 and 1997 Documentation Guidelines for office/outpatient E/M codes.

Another important change related to E/M in the 2019 final rule was a plan to add HCPCS Level II G codes (codes that start with the letter G) to reflect additional resources used for primary care and certain specialist visits. These codes were intended for use with level 2 to 4 visits. A new “extended visit” G code was planned for use with levels 2 to 4, as well, all beginning in 2021. These expectations have also changed, as you’ll discover later in this article.

AMA’s 2021 Office/Outpatient E/M Codes: New Patient

As an alternative to Medicare’s plans, the AMA developed new guidelines and code descriptors for office and outpatient E/M codes. The effective date was Jan. 1, 2021. Because this update has such a large impact on healthcare providers, the AMA posted the revised 2021 office and outpatient E/M guidelines and code descriptors for review before the effective date. Let’s start with the new patient codes and descriptors.

99201: The 2021 CPT^® code set does not include new-patient level-1 code 99201. As you’ll see below, the revised code descriptors for the remaining office and outpatient E/M codes use MDM or time to dictate code selection. Code 99201 required straightforward MDM, the same as 99202, and having two codes requiring the same level of MDM would be redundant.

99202-99205: In 2021, new patient codes 99202-99205 no longer require the three key components or reference typical face-to-face time. Instead, each service includes “a medically appropriate history and/or examination,” 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:

The descriptors for 2021 codes 99202-99205 all follow the same structure as the 99203 example above. Table 1 shows the requirements for the new patient E/M codes in 2021.

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(s) beyond the minimum required time of the primary 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 total time (List separately in addition to codes 99205, 99215 for office 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 about prolonged services provide more details about these codes.

AMA’s 2021 Office/Outpatient E/M Codes: Established Patient

The office and other outpatient E/M codes for established patients changed in line with the revisions to the new patient codes in 2021.

99211: Level-1 established patient E/M code 99211 is still available, but the 2021 code descriptor does not include the time reference that was in the 2020 descriptor:

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

Table 2 shows the requirements for the 2021 established patient codes. Note that the times required for each level differ for the new patient and established patient codes. For instance, level-5 new-patient code 99205 lists a time of 60-74 minutes while level-5 established-patient code 99215 lists 40-54 minutes.

You may use new prolonged services code +99417 as an add-on 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 code has its own rules.

2021 CPT^® E/M Guidelines Overview

Because of the 2021 changes to the office and outpatient E/M codes, the CPT^® E/M guidelines saw revisions, as well. Some of the guideline updates relate directly to the new code requirements, but the guidelines also feature changes throughout to ensure no outdated references involving the office/outpatient codes remain.

For instance, 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, Domiciliary, Rest Home, or Custodial Care, and Home E/M Services
• Guidelines for Office or Other Outpatient E/M Services

2021 CPT^® E/M Guidelines for Time 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 section of the 2021 E/M guidelines includes important information about proper use of the revised office and other outpatient codes. Here are the major points from the 2021 guidelines for Time:

• You may use time alone to select the correct code from 99202-99205 and 99212-99215. Note that 99211 is not in that list because no time is listed in that descriptor
• Counseling and/or coordination of care does not need to dominate an office or other outpatient E/M service for you to code the service based on time in 2021. But for other E/M services that you code based on time, you still need to meet the threshold of counseling and/or coordination of care taking up more than 50% of the visit.
• You use 99211 if clinical staff members perform the face-to-face visit under the supervision of the physician or other qualified healthcare professional.
• A shared or split visit is when a physician and one or more other qualified healthcare professionals perform the face-to-face and non-face-to-face work for the E/M visit. When you’re coding these visits based on time, sum the time spent by the physician and other qualified healthcare professionals to get a total time. You should count any time that the providers spend together to meet with or discuss the patient only once. For instance, if two providers meet for 15 minutes, you should add 15 minutes to the total time, not 30 minutes (15 minutes x two providers).
• A key shift for the office and other outpatient E/M codes is that the time referenced in the 2021 code descriptors is total time. The 2020 descriptors for these codes used intraservice time.
  • 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 time spent by 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 information with the patient, family, or caregiver; and care coordination.
  • When you count time for the 2021 codes, you should not include time spent on services you report separately. For instance, if you report care coordination using a separate CPT^® code, you should not include that service’s time in the time for the E/M code.
  • The total time also does not include time for activities the clinical staff normally performs.

Services Reported Separately: The 2020 CPT^® E/M guidelines included information about services reported separately, but the 2021 guidelines give this information its own heading and add some clarifications. In particular, note this line: “If a test/study is independently interpreted in order to manage the patient as part of the E/M service, but is not 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 E/M Services will help you understand the revised E/M codes and how to apply them in 2021.

The History and/or Examination portion of these E/M guidelines explains that office and other outpatient E/M 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 E/M determines the nature and extent of any history or exam for a particular service. Remember that code selection does not depend on the level of history or exam. That’s why the guidelines don’t quantify these elements.

The history and exam guidelines for office and outpatient E/M visits also specify that the “care team” may collect information, and the patient (or caregiver) may provide information, such as by portal or questionnaire. The reporting provider must then review that information.

2021 CPT^® E/M Guidelines for MDM

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

The MDM guidelines and table are in the CPT^® E/M guidelines section for Instructions for Selecting a Level of Office or Other Outpatient E/M Service, but you use them together with information and definitions in the section called Number and Complexity of Problems Addressed at the Encounter.

In the 2021 MDM guidelines, CPT^® states that MDM “includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option.” Three elements define MDM for office/outpatient visits in 2021, and they are similar but not identical to the 2020 elements:

• 1. The number and complexity of the problem or problems the provider addresses during the E/M 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 be reviewed and analyzed.” The 2021 guidelines list three categories for data: (1) tests, documents, orders, or independent historians, (2) independent test interpretation, and (3) discussion of management or test interpretation with external providers or appropriate sources. The latter term refers to non-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.
• 3. “The risk of complications and/or morbidity or mortality of patient management decisions made at the visit.” The 2021 guidelines make it clear that options considered, but not selected, are still a factor 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 care or choosing palliative care for a patient with advanced dementia and an acute condition.
  • The 2020 MDM guidelines included comparable wording, but 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’s in the CMS 1995 and 1997 Documentation Guidelines, as well as current CMS contractor audit tools, as a basis for the 2021 MDM updates.

The 2021 MDM table in the CPT^® E/M 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 Complexity of Data to be Reviewed and Analyzed
  • Risk of Complications and/or Morbidity or Mortality of Patient Management

In Tables 1 and 2 above, 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 instance, 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 second column shows the MDM level for the codes in column 1. The final three columns represent the three elements of MDM.

Table 3 shows the row from the CPT^® MDM table for codes 99203 and 99213 along with column headings to give you an idea of the structure. Pay attention to the note in the Level of MDM column reminding you that your final choice for the MDM level should be based on meeting requirements for two out of the three elements. (In 2020, the service had to meet two out of three elements in the much smaller table CPT^® provided for that code set.)

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

As Table 3 shows, for 99203 and 99213 the service has to meet the requirements for at least one of two categories. For codes 99204 and 99214, the service has to meet the requirements for one of three categories. For the highest-level codes, 99205 and 99215, the service has to meet the requirements for two of three categories. The lower-level codes don’t have categories in that column.

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 Encounter (which matches a column name in the MDM table). This part of the guidelines includes a brief discussion about how the problems addressed may affect code level selection. Under this header, you’ll also find many definitions that are important to MDM.

One key point the 2021 guidelines make is that the final diagnosis isn’t the only factor when you determine the complexity or risk. A patient may have several lower-severity problems that combine to cause higher risk, or the provider may have to perform an extensive evaluation to determine a problem is of lower severity.

The 2021 guidelines also take a 2020 rule and expand it, clarifying that you should not consider comorbidities and underlying diseases when you select the E/M level “unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.”

2021 MDM Terms and Definitions

To use the 2021 level of MDM table properly, you need to know CPT^®’s definitions for many terms. In fact, you need to know roughly two pages of definitions. Below is an overview of many of those terms, but you should review the official guidelines to see the complete list of definitions.

To qualify as 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 it, that still counts as addressed. But a simple note that another professional is managing a problem does not count as addressed. There must be additional assessment or care coordination to meet the requirements of addressing a problem. Another area that does not qualify as addressing the problem is referral without evaluation (by history, exam, or diagnostic studies) or consideration of treatment.

A self-limited or minor problem is defined almost identically by the 2020 and 2021 E/M guidelines, but the 2021 guidelines delete the crossed out text: “A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance.” The MDM table includes the term self-limited or minor problem in the column for Number and Complexity of Problems Addressed at the Encounter. Level-2 codes meet the threshold for “minimal” if there is one self-limited or minor problem addressed. Level-3 codes meet the threshold for “low” if two or more self-limited or minor problems are addressed.

Risk is related to the probability of something happening, but risk and probability are not the same for E/M office and outpatient coding purposes. For instance, high probability of a minor adverse effect may be low risk, depending on the case. The AMA intends the terms high, medium, low, and minimal risk to reflect the common meanings used by providers in their specialties. For MDM, base the level of risk on the consequences of the addressed problems when they’re appropriately treated. Risk also 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 same group practice or is classified as a different specialty or subspecialty. Review of external notes is included in the office/outpatient E/M codes for levels 3 to 5. Discussion with an external provider is included in levels 4 and 5.

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

Social determinants of health (SDOH) are economic and social conditions that effect health. SDOH is something you may be familiar with from ICD-10-CM coding, specifically categories Z55.- to Z65.-, Persons with potential health hazards related to socioeconomic and psychosocial circumstances. The 2021 MDM table references SDOH in an example of moderate risk from additional diagnostic testing or treatment because SDOH, like housing insecurity, may limit those options.

Drug therapy requiring intensive monitoring for toxicity is in the 2021 CPT^® MDM table as an example of high risk of morbidity from additional diagnostic testing or treatment. To be sure the case you’re coding qualifies as intensive monitoring for toxicity, review these conditions listed in the guidelines:

• The drug can cause serious morbidity or death.
• Monitoring assesses adverse effects, not therapeutic efficacy.
• The type of monitoring used should be the generally accepted kind for that agent, although patient-specific monitoring may be appropriate, too.
• Long-term or short-term monitoring is OK.
• Long-term monitoring occurs at least quarterly.
• Lab, imaging, and physiologic tests are possible monitoring methods. History and exam are not.
• Monitoring affects MDM level when the provider considers the monitoring as part of patient management.
• An example of drug therapy requiring intensive monitoring for toxicity is testing for cytopenia (reduction in the number of mature blood cells) between antineoplastic agent dose cycles.

Morbidity is a “state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.” Morbidity is an important term to understand for the acute and chronic illness definitions below.

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

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

The MPFS 2020 final rule addressed the substantial changes that the AMA announced for E/M office/outpatient codes in 2021, stating that Medicare would adopt the MDM guidelines revised by CPT^® and would allow the use of time or MDM for office/outpatient E/M code selection. The final rule also 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 rule confirmed that Medicare would generally adopt the AMA code and guideline changes, as planned. But medical coders and providers should stay alert 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 role of time changed for office and other outpatient E/M codes in 2021, the AMA revised the Prolonged Services section of the CPT^® code set.

Codes +99354 and +99355 for prolonged E/M services requiring direct patient contact changed from applying to the office or other outpatient setting to applying to the outpatient setting. The descriptors state that you should not use +99354 and +99355 as add-on codes with office/outpatient codes 99202-99205 and 99212-99215. The guidelines for these prolonged services codes (and other prolonged services codes) also 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 office/outpatient prolonged services code:

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 direct patient contact on the date of service. Remember that 99202-99205 and 99212-99215 also use total time rather than intraservice time in 2021.
• You will use +99417 once for each 15 minutes beyond the minimum required primary service time.
• There are only two appropriate primary codes: 99205, which represents the longest time among the new patient codes, and 99215, which represents the longest time 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. Under CPT^® rules you start counting based on the minimum time required for the code. For instance, 99205 represents 60-74 minutes in 2021. You may add +99417 as soon as the encounter reaches 75 minutes, which is 15 minutes beyond the minimum required time of 60 minutes. You should not assign another unit of +99417 until the encounter reaches 90 minutes, which is 15 minutes more than 75 minutes. In other words, you assign 99205 and +99417 to report 75-89 minutes. For 90-104 minutes, you should report 99205 and two units of +99417.

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

Keep in mind that Medicare has created a code to use in place of +99417, as will be explained below.

Medicare-Specific HCPCS Code for Prolonged Services

Medicare created a new HCPCS Level II code for use in place of CPT^® code +99417 when billing Medicare for prolonged office/outpatient E/M services:

The main difference between the two codes is that +99417 applies to prolonged services 15 minutes beyond the minimum required time and +G2212 applies to prolonged services 15 minutes beyond the maximum required time.

The MPFS 2021 final rule explained Medicare’s position that allowing +99417 for 15 minutes beyond the minimum time, instead of the maximum, results in “double counting” time. The MPFS provides this example: 99215 has a time range of 40-54 minutes. If the provider reports prolonged services at 55 minutes, then 14 of those “prolonged” minutes are also captured in 99215. The AMA argued against Medicare’s reasoning when commenting on MPFS 2021, but Medicare finalized +G2212 and requires that code for Medicare claims. Healthcare organizations should confirm with other payers which prolonged services code they accept and which rules they apply.

Medicare-Specific HCPCS Code for Visit Complexity

The 2019 MPFS final rule included a plan to create two new G codes to represent the visit complexity inherent to certain services, with one code for designated specialists and a second code for primary care providers. The 2020 MPFS final rule changed that, adopting a single new G code instead for use in 2021. The 2021 MPFS final rule changed the descriptor slightly and confirmed the code would be part of the 2021 HCPCS Level II code set:

The MPFS 2021 final rule indicated Medicare would reimburse providers for this code, but December 2020 legislation related to COVID-19 relief changed this by including a moratorium on payment for G2211 until at least January 2024. This delay also 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 40% of allowed charges for MPFS services, and office/outpatient E/M visits comprise approximately 20% of allowed charges, the MPFS 2021 final rule states. As a result, pricing of these codes is an important subject, both for providers and for Medicare.

Fees on the MPFS are calculated using work relative value units (RVUs), malpractice RVUs, and practice 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 also can affect how much a provider receives from Medicare.

Table 5 shows the first-quarter 2021 and fourth-quarter 2020 total RVUs for 99202-99215 (the MPFS is updated quarterly). The table also includes the 2021 RVUs for new prolonged services code +G2212. MPFS facility RVUs are often lower than non-facility (office) RVUs because when a physician provides services in a facility, the physician is responsible for fewer practice expenses. Remember that the final reimbursement amounts for E/M services will depend on more than just these RVUs.