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.

DOWNLOAD: CPT® Evaluation and Management – Code and Guideline Changes