2021 Evaluation and Management (E/M) Code Changes

by | Jan 23, 2021 | ICD, Medical Billing

Each year, a number of Evaluation and Management Code Changes are announced, and these E&M code changes must be adhered to throughout the calendar year and beyond, unless they are superseded by later changes. For calendar year 2021, the E&M code changes described here will be in effect, and must be used by medical personnel when making any kind of medical claims. Excerpts from the code changes document issued by the American Medical Association pertaining to this year’s changes are included below. This kind of uniformity is of course necessary, so as to avoid total chaos in the realm of medical billing

Coding changes regarding time 

It is necessary to include time as a factor in medical claims, so as to determine the most appropriate type of medical service. For some outpatient services, it will be possible to use time by itself as the appropriate code level, for instance using codes 99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215. Since most categories of service use time in a different way, it becomes important to review and understand the instructions for each of these categories. It is often difficult to provide precise estimates of the time which is spent on a face-to-face basis with any patient, because it happens fairly often that patient encounters occur on multiple occasions and for varying amounts of time. For those medical codes mentioned above, time should be considered the total face-to-face time on the actual date of any patient encounter.

Additionally, there was a significant change to the Evaluation and Management Code effective January 1, 2021. CPT code 99201 will be deleted. For new patient codes, times begin at 15–29 minutes for CPT code 99202 and then advance in 15-minute increments with 99205 assigned 60–74 minutes. For existing patients, the time element was removed from CPT code 99211.

Separately reported services 

It is allowable to report any specifically identifiable procedure separately, as long as it was performed on the date of the E/M services. For example, any physician-administered diagnostic tests for which CPT codes exist can be reported separately, and it is also allowable to claim the time needed to interpret the results of those diagnostic tests. Any tests or interpretations which are not reported separately, will be considered standard decision-making on the part of the physician. 

Examinations and patient histories 

Patient examinations can be reported, using the appropriate codes, as can interviews which constitute a review of the patient’s medical history. It is at the discretion of the physician what the nature and extent of such interviews should include, and information can be gathered both verbally, and through questionnaires or other written vehicles. Patient portals may also be used in the gathering of patient information, provided that it relates to the patient’s medical background, and will be considered during future treatments.

Number of issues addressed, and levels of complexity 

It is entirely possible that several issues will be addressed during a single medical encounter with a patient, and these issues may be characterized by varying degrees of complexity. There are specific guidelines which relate to the complexity of any issues which might be treated during a patient encounter, and that of course will impact the medical billing code used. As an example, a chronic illness would be handled in a different manner than an acute illness would, and that means different billing codes must be used when making any claims. 

Office and outpatient services 

A patient is considered an outpatient until he/she is admitted to a healthcare facility as an inpatient. Care must be taken to use the appropriate billing codes to reflect this potentially changing status. There is a complete set of codes which can be used for delivering outpatient services, just as there are corresponding codes which must be used for observation care, for inpatient services, discharge services, and for any kind of services which are provided in the emergency room.

New Patients

The billing codes used to cover new patients are 99202-99205, and they are reflective of the length of time necessary to conduct a physical examination of the patient, as well as to conduct some kind of interview regarding the patient’s medical history and background. The different codes are used so as to denote the length of time which was necessary to accomplish the exam and patient history interview. For example, code 99202 would be used for a session which lasted between 15 and 29 minutes, whereas 99205 would be used for a session between 60 and 74 minutes duration.

Established Patients

In the same way that several different billing codes are used to represent the time needed for a session with a new patient, a set of different codes must be used for sessions with established patients, those being 99211-99215. Each of these will also represent varying lengths of time necessary to deliver services to the patient at the session, with 99212 being used for 10-19 minutes of time and 99215 being used when the time required falls between 40 and 54 minutes.

Prolonged Services 

It will be necessary to use billing codes 99354 thru 99357 when the services delivered to a patient are considered to be beyond usual service, either in an outpatient setting, or an inpatient setting. These are face-to-face services which include other services not considered face-to-face, such as those which might be administered in a hospital setting or a nursing facility. These are services which can be reported in addition to primary services offered, and it will be necessary to choose the correct billing codes when claiming such services as supplies provided to the patient, or other procedures which are performed on the patient during this period.

"*" indicates required fields