2021 E/M Guidelines

Presented by:
Nitesh Kumar, CPC, PAHM, LSSBB
Senior Business Analyst
EXL

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 Disclaimer
 This material is designed to offer basic information for 2021
E/M Guidelines. The information presented here is based on
the experience, training and interpretation of the author.
Although the information has been carefully researched and
checked for accuracy and completeness, the instructor does
not accept any responsibility or liability with regarding errors,
omissions, misuse or misinterpretation. This handout is
intended as an educational guide and should not be
considered a legal/consulting opinion.

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 Agenda

• Overview of E/M

• 2021 E/M Guidelines: What’s Changing and

what we need to do to Prepare.

• Time

• Medical Decision Making (MDM)

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 E/M Overview

Evaluation and Management (E/M)

Evaluation and management coding (commonly known as E/M coding or E&M
coding) is a medical coding process in support of medical billing. This
allows medical service providers to document and bill for reimbursement for services
provided.

Selecting the code that best represents the service furnished

Billing Medicare for an E/M service requires the selection of a Current Procedural
Terminology (CPT) code that best represents:
• Patient type
• Setting of service
• Level of E/M service performed

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 E/M Overview

Patient Type
For purposes of billing for E/M services, patients are identified as either new or
established, depending on previous encounters with the provider.

New Patient: An individual who did not receive any professional services from the
physician/non-physician practitioner (NPP) or another physician of the same specialty
who belongs to the same group practice within the previous 3 years.

Established Patient: An individual who receives professional services from the

physician/NPP or another physician of the same specialty who belongs to the same
group practice within the previous 3 years.

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 E/M Overview

Setting of Service
E/M services are categorized into different settings depending on where the service is
furnished. Examples of settings include:

• Office or other outpatient setting

• Hospital inpatient
• Emergency department (ED)
• Nursing facility (NF)

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 E/M Overview

Level of E/M Service Performed

E&M has 7 components

• History
• Examination
• MDM
• Counseling
• Coordination of care
• Nature of presenting problem
• Time

The three key components when selecting the appropriate level of E/M services
provided are history, examination, and medical decision making.

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 How the Changes Occurred

• Providers need a mechanism to be accurately reimbursed for the time and effort
that they expend in providing care. However, 1995 and 1997 E/M guidelines in
place today are overly complex and incentivize or reward the quality of
documentation over the quality.

• Between July 2018 and July 2019, the AMA worked with CMS and convened
specialty societies and other health professionals to simplify and streamline the
coding and documentation for E/M office visits, making them clinically relevant,
and reducing excessive administrative burden.

• Reducing documentation overload and providing physicians more time with

patients, not paperwork, was the fundamental purpose of overhauling the E/M
office visit guidelines.

• AMA CPT has issued a new set of guidelines for 2021 intending to help simplify E/M
leveling for office and other outpatient services.

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 Major Changes
• Office Visit and Other Outpatient E/M Services
• Codes 99202-99205 & 99212-99215
• Deletion of 99201

• Office or other outpatient services include a medically appropriate history and/or

physical examination, when performed.

• The nature and extend of the history and/or physical examination is determined by
treating physician or other qualified healthcare professional reporting the service.

• The extent of history and physical examination is not an element in selection of

office or other outpatient services.

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 Instructions for selecting Office or Other
Outpatient E/M Level
Select the appropriate level of E/M services based on the
following:
• The level of the medical decision making as defined for each services;

• The total time for E/M services performed on the date of the encounter.

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 Work RVU 2020 and 2021
E/M 2020 (Q4) 2021 (Proposed) % Increase
99201 0.48 Deleted in 2021 -
99202 0.93 0.93 0%
99203 1.42 1.60 13%
99204 2.43 2.60 7%
99205 3.17 3.50 10%
99211 0.18 0.18 0%
99212 0.48 0.70 46%
99213 0.97 1.30 34%
99214 1.50 1.92 28%
99215 2.11 2.80 33%

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 Time Documentation
(For Office and Other Outpatient Services (99202 – 99215)

Time:
• Total time on the date of the encounter (office or other outpatient
services [99202-99205, 99212-99215]): For coding purpose, time
for these services is the total time on the date of the encounter.

• It includes both the face-to-face and non-face-to-face time personally

spent by the physician and/or other qualified healthcare
professional(s) on the day of the encounter (includes time in activities
that require the physician or other qualified healthcare professional
and does not include time in activities normally performed by clinical
staff).

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 Time- Activities that count when performed

 Preparing to see the patient (e.g., review of tests).

 Obtaining and/or reviewing separately obtained history.
 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 healthcare 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 cordination (not separately reported).

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 Not Included In Time

• Separate reported tests / procedures

• Staff time
• Slow charting
• Any element performed on different date

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 AMA Time Calculation 2020 and 2021
E/M Code 2020 Time (In 2021 Proposed
Minutes) Time (In Minutes)
99201 10 Deleted • For services of 75 minutes or
99202 20 15-29 longer for New Patient (99205)
see Prolonged Services codes.
99203 30 30-44
99204 45 45-59 • If < 15 minutes No Code
99205 60 60-74
99211 5 N/A
99212 10 10-19 • For services of 55 minutes or
longer for Established Patient
99213 15 20-29 (99215) see Prolonged Services
99214 25 30-39 codes.
99215 40 40-54
• If < 10 minutes No Code

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 New Prolonged Codes 99417/G2212
New Patient - 99205+ Established Patient - 99215+

Code Time (minutes) Code Time (minutes)

99417 75 – 89 99417 55 - 69

99XXX 90 -104 99XXX 70 - 84

99XXX 105 + 99XXX 85 +

• The AMA has developed a new CPT code for 15 minutes of prolonged care, done
on the same day as office/outpatient codes 99205 and 99215. The new code is
99417

• Medicare has assigned a status indicator of invalid to code 99417, and developed a
HCPCS code to replace it, G2212

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 Scenario #1 - Est Pt
CC: Allergic Reaction

Hx: Pt broke out in itchy rash yesterday. No dysphagia or SOB. Pt does have
throbbing headache. Pt recently finished Sulfa for UTI. Prescribed by Dr A.

Exam: Classical urticarial rash all over including face

A/P: Severe Hives with headache. Injection of Depo Medrol given.

Prednisone for 20 mg x3 day. OTC Benadryl Q 6 hours. Medication side
effect and treatment options discussed. Spent 62 minutes obtaining records
from Dr A, evaluating pt and discussing tx options

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 Scenario #1 - Est Pt
What is the E/M Level?

A. 99213
B. 99214
C. 99215
D. 99215 and 99417

Answer: D

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 Scenario #2 - New Pt
CC: ‘Goopy’ left eye

Hx: Mother reports pt woke up with left eye matted shut. Both eyes are red
and itchy today.

Exam: left eye injected no periorbital edema

A/P: Conjunctivitis Rx Polytrim drops. Instructed mother to call if patient

develops fever. Discuss treatment options with >50% counseling time for 15
minutes. Start time: 09:20 End Time: 09:40

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 Scenario #2 - New Pt
What is the E/M Level?

A. 99202
B. 99212
C. 99203
D. 99213

Answer: A

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 Medical Decision Making
Medical decision making includes establishing diagnoses, assessing the
status of a condition, and/or selecting a management option. MDM in the
office and other outpatient services code is set to defined by 3 elements:

1. The number and complexity of problem(s) that are addressed during

the encounter.

2. The amount and/or complexity of data to be reviewed and analyzed.

3. The risk of complications, morbidity, and/or mortality of patient

management decisions made at the visit, associated with the patient’s
problem(s), the diagnostic procedure(s), treatment(s).

• If time is not given, the level of service will be based on the documented
medical decision making.

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 Elements for Each Level of Medical Decision Making
TYPE OF NUMBER OF AMOUNT AND/ RISK OF SIGNIFICANT
DECISION DIAGNOSES OR OR COMPLEXITY COMPLICATIONS,
MAKING MANAGEMENT OF DATA TO BE MORBIDITY, AND/OR
OPTIONS REVIEWED MORTALITY
Straightforward Minimal Minimal or None Minimal

Low Low Limited Low

Moderate Moderate Moderate Moderate

High High Extensive High

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 Problems Addressed- assessing current documentation
• A problem is addressed or managed when it is evaluated or treated at the
encounter by the physician or other qualified healthcare professional
reporting the service.
• This includes consideration of further testing or treatment that may not be
elected by virtue of risk/benefit analysis or
patient/parent/gurdian/surrogate choice.
• Notation in the patient’s medical record that another professional is
managing the problem without additional assessment or care cordination
documented does not qualify as being addressed or managed by the
physician or other qualified healthcare professuional reporting the services.
• Referral without evaluation (by history, exam, or diagnostic study) or
consideration of treatment does not qualify as being addressed or
managed by the physician or other qualified healthcare professional
reporting the service.

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 Data – assessing current documentation

• This data includes medical records, tests, and/or other

information that must be obtained, ordered, reviewed, and
analyzed for the encounter.
• This includes information obtained from multiple sources or
interprofessional communications that are not separately
reported.
• It includes interpretation of tests that are not separately
reported.
• Ordering a test is included in the category of test results and
the review of the test result is part of the encounter and not a
subsequent encounter.

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 Data – assessing current documentation

Data is divided into three categories:

1. Tests, documents, orders, or independent historian(s). (Each

unique test, order or document is counted to meet a
threshold number)
2. Independent interpretation of tests.
3. Discussion of management or test interpretation with
external physician or other qualified healthcare professional
or appropriate source.

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 Risk

• The risk of complications, morbidity, and/or mortality of patient

management decisions made at the visit, associated with the
patient’s problem(s), the diagnostic procedure(s), treatments(s).
• This includes the possible management options selected and those
considered, but not selected, after shared medical decision making
with the patient and/or family.
• For example, a decision about hospitalization includes consideration
of alternative levels of care. Examples may include a psychiatric
patient with a sufficient degree of support in the outpatient setting
or the decision to not hospitalize a patient with advanced dementia
with an acute condition that would generally warrant inpatient care,
but for whom the goal is palliative treatment.

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 Table of Medical Decision Making (MDM)
Elements of Medical Decision Making
Code Level of MDM
(Based on 2 out Number and Complexity Risk of Complications
of Problems Amount and/or Complexity of Data to be and/or Morbidity
of 3 Elements Reviewed and Analyzed
of MDM) Addressed or Mortality of
*Each unique test, order, or document contributes Patient
to the combination of 2 or combination of 3 in Management
Category 1 below.
99211 N/A N/A N/A N/A
Straightforward Minimal Minimal or none Minimal risk of
99202 • 1 self-limited or minor morbidity from
99212 problem additional diagnostic
testing or treatment
99203 Low Low Limited Low risk of
99213 • 2 or more self-limited (Must meet the requirements of at least 1 of the 2 morbidity from
or minor problems; categories) additional
or diagnostic testing or
•1 Category 1: Tests and documents treatment
stable
chronic • Any combination of 2 from the following:
illness; • Review of prior external note(s) from each
or unique source*;
• 1 acute, uncomplicated • review of the result(s) of each unique test*;
illness or injury • ordering of each unique test*
or
Category 2: Assessment requiring an independent
historian(s)
(For the categories of independent interpretation of
tests and discussion of management or test
interpretation, see moderate or high)

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 Table of Medical Decision Making (MDM)
99204 Moderate Moderate Moderate Moderate risk of morbidity
99214 • 1 or more chronic (Must meet the requirements of at least 1 out of 3 categories) from additional diagnostic
illnesses with Category 1: Tests, documents, or independent historian(s) testing or treatment
exacerbation, • Any combination of 3 from the following:
progression, or • Review of prior external note(s) from each unique Examples only:
side effects of source*; • Prescription drug
treatment; • Review of the result(s) of each unique test*; management
or • Ordering of each unique test*; • Decision regarding minor
• 2 or more stable • Assessment requiring an independent historian(s)
or surgery with identified
chronic illnesses;
or Category 2: Independent interpretation of tests patient or procedure risk
• 1 undiagnosed • Independent interpretation of a test performed by another factors
new problem physician/other qualified health care professional (not • Decision regarding elective
with uncertain separately reported); major surgery without
prognosis; or identified patient or
or Category 3: Discussion of management or test procedure risk factors
• 1 acute illness interpretation • Diagnosis or treatment
with systemic • Discussion of management or test interpretation with significantly limited by
symptoms; external physician/other qualified health care social determinants of
or professional\appropriate source (not separately health
• 1 acute reported)
complicated
injury

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 Table of Medical Decision Making (MDM)
99205 High High Extensive High risk of morbidity from
99215 • 1 or more chronic illnesses (Must meet the requirements of at least 2 out of 3 additional diagnostic
categories)
with severe exacerbation, testing or treatment
progression, or side effects of
Category 1: Tests, documents, or independent
treatment; Examples only:
or historian(s)
• Drug therapy requiring
• 1 acute or chronic illness or • Any combination of 3 from the following:
intensive monitoring for
injury that poses a threat to • Review of prior external note(s) from each
toxicity
life or bodily function unique source*;
• Decision regarding elective
• Review of the result(s) of each unique test*;
major surgery with
• Ordering of each unique test*;
• Assessment requiring an independent identified patient or
historian(s) procedure risk factors
or • Decision regarding
Category 2: Independent interpretation of tests emergency major surgery
• Independent interpretation of a test • Decision regarding
performed by another physician/other hospitalization
qualified health care professional (not • Decision not to resuscitate
separately reported); or to de- escalate care
or because of poor prognosis
Category 3: Discussion of management or test
interpretation
• Discussion of management or test
interpretation
with external physician/other qualified health
care professional/appropriate source (not
separately reported)

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 Scenario #3 – MDM Question
CC: New Pt Consult requested by Dr B in cardiology for PT ESRD

Hx: 69 y.o. male with DM2, HTN, ESRD, CAD, CVA, SHPT, TMA infection with
gangrene. Pt is on abx, getting vascular eval w/ angio later this week. Last
dialysis was Monday.

A/P: ESRD – I spoke to nephrologist, Dr C, about recent results of AVF and

urine results. Pt having dialysis later today. HTN fair control, get HDL,
continue meds. SHPT get phos, thyroid panel. RT Foot gangrene s/p recent
TMA, vascular eval pending angio. OK to proceed with contrast from renal
standpoint.

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 Scenario #3 – MDM Question
What is the overall MDM Level?

A. Straightforward
B. Low
C. Moderate
D. High

Answer: D

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 Example of Code Description 2020 and 2021
AMA CPT 2020 AMA CPT 2021

Code Description Code Description

99213 Office or other outpatient visit for the 99213 Office or other outpatient visit
evaluation and management of an for the evaluation and
established patient, which requires at least 2 management of an established
of these 3 key components: An expanded patient, which requires a
prolem focused history; An expanded medically appropriate history
problem focused examination; Medical and/or examination and low
decision making of low complexity. level of medical decision
Counseling and/or coordination of care with making.
other physicians, other qualified healthcare When using time for code
professionals, or agencies are provided selection, 20-29 minutes of
consistent with the nature of the problem(s) total time is spent on the date
and the patient’s and/or family’s needs. of the encounter.
Usually, the presenting problem(s) are of low
to moderate severity.
Typically, 15 minutes are spent face-to-face
with the patient and/or family.

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 Example of Code Description 2020 and 2021
AMA CPT 2020 AMA CPT 2021

Code Description Code Description

99214 Office or other outpatient visit for the 99214 Office or other outpatient visit
evaluation and management of an for the evaluation and
established patient, which requires at least 2 management of an established
of these 3 key components: A detailed patient, which requires a
history; A detailed examination; Medical medically appropriate history
decision making of moderate complexity. and/or examination and
Counseling and/or coordination of care with moderate level of medical
other physicians, other qualified healthcare decision making.
professionals, or agencies are provided When using time for code
consistent with the nature of the problem(s) selection, 30-39 minutes of
and the patient’s and/or family’s needs. total time is spent on the date
Usually, the presenting problem(s) are of of the encounter.
moderate to high severity.
Typically, 25 minutes are spent face-to-face
with the patient and/or family.

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 Key Point to keep in Mind

• Retains 5 levels of coding for established patients, reduces the number of

levels to 4 for office/outpatient E/M visits for new patients, and revises
the code definitions

• Revises the times and medical decision making process for all of the
codes, and requires performance of history and exam only as medically
appropriate

• Allows clinicians to choose the E/M visit level based on either medical
decision making or time

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 Resources
• CMS Website
• AMA Website
• AAPC Website

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 Thank You

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