Evaluation and Management E/M visits will no longer be what they used to be. Effective January 1st, 2021 the level to be used will be dependent on time or Medical Decision Making (MDM).

We at Taino Consultants Inc. have been studying these changes and as a service to the healthcare community created the following summary:

 

EVALUATION AND MANAGEMENT (E/M) VISITS:

  • 99201 has been deleted.
  • E/M level is selected based on medical decision making (MDM) or total time spent
  • Documentation of patient history and medical examination would only be required when clinically appropriate, i.e. there is no required level of history or exam for visits

 

Time

  • Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service.
  • Except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services (CPTs 99202 – 99205, 99212-99215).
  • Time may only be used for selecting the level of the other E/M services when counseling and/or coordination of care dominates the service.
  • When prolonged time occurs, the appropriate add-on code may be reported.
  • It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).
  • The appropriate time should be documented in the medical record when it is used as the basis for code selection.
  • Time spent performing separately reported services other than the E/M or psychotherapy service is not counted toward the prolonged services time.
  • Prolonged services should be coded using 99354-99355. These codes cover the total duration of face-to-face time spent by a physician or other qualified health care professional on a given date providing prolonged service in the outpatient setting, even if the time spent by the physician or other qualified health care professional on that date is not continuous.
  • Physician/other qualified health care professional time includes the following activities, when performed:
  • preparing to see the patient (i.e. 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 health care 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 coordination (not separately reported)

 

Medical Decision Making (MDM)

  • Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option.
  • Medical decision making in the office and other outpatient services code set is defined by three elements:
    • The number and complexity of problem(s) that are addressed during the encounter.
    • The amount and/or complexity of data to be reviewed and analyzed. 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 result(s) and the review of the test result is part of the encounter and not a subsequent encounter. Data is divided into three categories: • Tests, documents, orders, or independent historian(s). (Each unique test, order or document is counted to meet a threshold number)
      • Independent interpretation of tests.
      • Discussion of management or test interpretation with external physician or other qualified healthcare professional or appropriate source
    • 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).

 

Medical Decision Making (MDM) Types

MDM CPT Code MDM Elements

Time (Mins)
N/A 99211 (established) N/A N/A
Straightforward 99202 (New)

99212 (established)

 Problems: 1 self-limited or minor

Data Complexity: Minimal

Morbidity: Minimal

 15-29
Low 99203 (New)

99213 (established)

 Problems: Low

§  2 or more self-limited or minor problems; or

§  1 stable chronic illness; or

§  1 acute, uncomplicated illness or injury

Data Complexity: Must meet one of the categories below.

§  Category 1: Tests and documents. Any combination of 2 from the following:

·       Review of prior external note(s) from each unique source;

·       review of the result(s) of each unique test;

·       ordering of each unique test

§  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)

Morbidity: Low risk of morbidity from additional diagnostic testing or treatment

 30-44
Moderate 99204 (new)

99214 (established)

 Problems:

§  1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or

§  2 or more stable chronic illnesses; or

§  1 undiagnosed new problem with uncertain prognosis; or

§  1 acute illness with systemic symptoms; or

§  1 acute complicated injury

Data Complexity: Must meet one of the categories below.

§  Category 1: Tests, documents, or independent historian(s). Must be any combination of 3 from the following:

·       Review of prior external note(s) from each unique source;

·       Review of the result(s) of each unique test;

·       Ordering of each unique test;

·       Assessment requiring an independent historian(s)

§  Category 2: Independent interpretation of tests another physician/other qualified health care professional (not separately reported);

§  Category 3: Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported)

Morbidity: Moderate risk

 45-59
High 99205 (New)

99215 (established)

 Problems:

§  1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or

§  1 acute or chronic illness or injury that poses a threat to life or bodily function

Data Complexity: Must meet one of the categories below.

§  Category 1: Tests, documents, or independent historian(s). Must be any combination of 3 from the following:

§  Review of prior external note(s) from each unique source;

§  Review of the result(s) of each unique test;

§  Ordering of each unique test;

§  Assessment requiring an independent historian(s)

§  Category 2: Independent interpretation of tests performed by another physician/other qualified health care professional (not separately reported);

§  Category 3: Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)

Morbidity: High Risk

 60-74

 

Other Key Concepts

A patient is considered an outpatient until inpatient admission to a health care facility occurs.

 

Description/Location Codes
Office or in an outpatient or other ambulatory facility 99202 – 99215
Emergency department 99281-99285
Observation care 99217-99226
Observation or inpatient care services (including admission and discharge services) 99234-99236

 

New vs Established Patient

New A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
Established An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

 

 

Understand that the information presented above highlights only a few areas of the changes and that we recommend you become familiar with these changes and or consult a professional to assist with the incorporation of these changes into your Practice.