A Closer Look at 2021 Outpatient and Office E/M Coding

If you code evaluation and management (E/M) services, you’ve probably already heard that significant changes are ahead in 2021, specifically for office visits. The American Medical Association (AMA) – the creator of CPT® coding – will be changing the criteria to assign E/M codes to make the process more straightforward, while also considering the natural workflows already happening in day-to-day healthcare.

There are two fundamental ways to code E/M office visits (using time or medical decision making) and that will not change. What will change is the face-to-face time requirements and the way medical decision making is assessed. This blog will dig a bit deeper into the ins-and-outs of using time as the criteria.

Coding E/M visits with time

Time has always been a component of E/M coding. However, starting in 2021, office and outpatient providers will have the option to use time alone as the key criteria to select the level of service. The standard of more than half of the encounter being used for counseling or coordination of care will no longer apply. E/M time will still be defined as face-to-face interactions with qualified health providers (QHPs). It is important to remember that CPTs for things like coordination of care already exist, so if that is what a provider is doing during the extended time, he or she should code for that CPT rather than adding that time toward the E/M. 

If a separate CPT does not already exist, the following activities count for physician time during an E/M visit:

  • Preparing to see a patient (i.e., review of tests)
  • Obtaining and/or reviewing a separately obtained history
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests or procedures
  • Referring and communicating with other health care professionals
  • Documenting clinical information in the patient record

Time increments will increase in 2021

A quick comparison of physician time today for new patient visits as compared to the requirements of 2021:

2020 typical physician time

2021 time only requirements

Level 2

10 minutes

15-29 minutes

Level 3

15 minutes

30-44 minutes

Level 4

25 minutes

45-59 minutes

Level 5

40 minutes

60-74 minutes

Of course, the time will need to be clearly documented in the patient record if it is the sole criteria for coding.

Correct coding for prolonged clinical staff time

If the total clinical face-to-face time spent on a patient’s case (by a QHP or clinical staff) goes beyond the E/M time allotment, there will still be an option to layer prolonged service CPTs to the claim. Codes 99415 and 99416 will still be available for instances when it is necessary to administer prolonged clinical staff services with physician or QHP supervision. These same-day E/M services will not need to be continuous. These codes are used in conjunction with the outpatient E/M codes and include the service that is in addition to the typical service time.  These prolonged service codes can only be utilized once the prolonged service time exceeds 45 minutes.

99415 is used to report the first hour of prolonged services beyond the typical face-to-face time of the primary service; 99416 is used to report each additional 30 minutes.  99415 should only be used once per date of service. 

What about coding for extended physician time?

There will also be a code (tentatively named 99XXX) that will be used to assign prolonged physician time used on 99205 and 99215 visits only as these are the highest-level service. Unlike 99415 and 99416, which will indicate an hour and a half-hour increment, respectively 99XXX will be 15-minute increments used after the allotted minutes of the initial CPT.

Say goodbye to 99201 in 2021

You may have noticed that there is not a level one in the above table of QHP time requirements. That’s because the level one new patient visit will be eliminated. The level one established visit will remain, (99211) but does not require face-to-face physician time (some office call these ‘nurse-visits’.) An example of a 99211 visit would be when a patient visits an office to have a TB test checked by clinical staff. If you think your office still needs to use 99201, consider consulting a professional coding professional to be sure.

Beware of payer differences

Since CMS worked with the AMA to redefine E/M coding, the new criteria will be used with Medicare patients (unless announced otherwise) – but that does not mean it will be used with all payers. It will be critical to check with each payer to confirm it will be using the new methodologies; otherwise, the old rules will still apply.

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