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Effective January 1st, 2021, the CPT® Evaluation and Management (E&M) coding and documentation requirements have been changed.
- Medical decision making is revised in the following ways:
- Clarifying when reporting a test that is considered, but not selected after shared decision making.
- Providing a definition of “Analyzed” for reporting tests in the data column.
- Clarifying the definition of a “unique” test.
- Clarifying what is meant by “discussion” between physicians, and other qualified health care professionals and patients.
- Providing a definition of major vs minor surgery.
- Clarification around which activities are not counted when reporting time as a key criterion for code level selection.