Effective Jan. 1, 2021, the Centers for Medicare & Medicaid Services (CMS) is aligning evaluation and management (E/M) coding with changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits.

This new evaluation and management services guide affects CPT codes 99201-5 and 99211-5. (Table 1).

New	Established
99201	99211
99202	99212
99203	99213
99204	99214
99205	99215

Content

• Introduction
• Coding Based on Time
• Coding Based on your Medical Decision-Making
• Summary

Introduction

This is the first revision since the 1995 and 1997 documentation guidelines for evaluation and management services. Previously, Medicare required an elaborate analysis of several components of your documentation to define the level of the visit or E/M service you provided.

The CMS’s Patients Over Paperwork initiative streamlines regulations to reduce health-care providers’ administrative burden and decrease unnecessary documentation–in other words, to increase efficiency and avoid what is known as “note bloating.” This should also result in a decreased need for audits.

Before these new guidelines, you typically determined the appropriate level of E/M service based on three key components: history, examination, and medical decision-making. Or, if the encounter was dominated (>50%) by counseling and/or coordination of care, you could bill based on time.

If you felt frustrated by all the complexity it took to determine the right code for your visit, we have good news for you. CMS now requires history and exam only as medically appropriate for all levels of E/M coding. This means you need to focus only on the medical decision-making component to determine the level of your visit.

You no longer need to be concerned about not having enough elements or descriptors in your history of present illness or about documenting a complete review of more than 10 systems to meet the criteria for a comprehensive history. For example, now you don’t need to document that you looked at the patient’s ear when she came for a urinary tract infection or that you asked your 90 year-old patient about his family history of heart disease. 

You can learn more about the previous guideline by reading this article.

Clinicians now need to document only interim or pertinent history and relevant physical exam findings. Another welcomed change is that CMS will now allow the use of documentation of chief complaint or history of present illness recorded by ancillary staff or provided by the patient itself. This is a boost to team documentation efforts as your medical assistant could help with the documentation of your visit notes. Imagine the patient being able to provide some follow-up information, either through the online portal or by questionnaire, for you to review before the visit, and you being able to use that information as part of your progress note. 

We plan to capitalize on this new rule with our new Chartnote web app. But more on that later.

Before 2021

2021 and After

HPI:  Presents with rhinorrhea, nasal congestion, headache, sore throat, cough, non-productive.  Symptoms present for days.  No SOB/wheezing.  No fever.  No sick contacts. PMH: MI with stent placement in 2012. PSH: Colonoscopy in 2000. FHx: Mom with breast cancer. SHx: Drinks 2 glasses of wine a day. PE: General: No acute distress. Awake and conversant.  Eyes: Normal conjunctiva, anicteric. Round symmetric pupils.  ENT: Tympanic membranes are clear, No sinus tenderness. Mild pharyngeal erythema, no exudates. Nasal mucosa erythematous and edematous. Clear rhinorrhea.  Neck: Neck is supple. Tender anterior lymphadenopathy.  Respiratory: Respirations are non-labored. Lungs are clear to auscultation. No wheezing.  Skin: Warm. No rashes or ulcers.  Psych: Alert and oriented. Cooperative. Appropriate mood and affect. Normal judgment.  CV: Normal rate. Regular rhythm. No murmur.  MSK: Normal ambulation. No clubbing or cyanosis.  Neuro: Sensation and CN II-XII grossly normal.  A/P: # URI.  Likely viral.  Reassurance. Supportive care.  Increase fluid intake, rest.  Fever control with Tylenol/Ibuprofen.   OTC decongestant, pseudoephedrine, Benadryl.  Salt water gargles, ice chips to soothe throat tid. Lozenges.  Nasal saline prn.  Return to clinic if not improved over the next several days or if getting worse.

HPI: Here with URI symptoms including sore throat. No fever. PE: Mild pharyngeal erythema, no exudates. Tender anterior lymphadenopathy.  A/P: # URI.  Likely viral.  Reassurance. Supportive care.  Increase fluid intake, rest.  Fever control with Tylenol/Ibuprofen.   OTC decongestant, pseudoephedrine, Benadryl.  Salt water gargles, ice chips to soothe throat tid. Lozenges.  Nasal saline prn.  Return to clinic if not improved over the next several days or if getting worse.

Coding Based on Time

With this simplification of the guidelines, clinicians now have only two options to choose from when deciding how to select the E/M visit level: Either by determining the complexity of the medical decision-making or based on time.

When using time for code selection, it is important to shine some light on another change in the rules. Before, a health-care provider could only use time for billing if the encounter was dominated by counseling and/or coordination of care (>50%). Now, time may be used to select a code level whether or not counseling and/or coordination of care dominates the service. This is not limited to the face-to-face encounter; it incorporates the total time on the day of the encounter. This includes pre-charting, talking to family/caregiver, and time spent on documentation (even “pajama time”). CMS recognizes that sometimes it takes more time and work to figure out what’s going on with the patient than to conduct the actual visit itself.

Established	15-29	30-44	45-59	60-88	>89	>104	Time (min)
	99212	99213	99214	999215	+99417	+99417 (x2)	E/M code
New	10-19	20-29	30-39	40-68	>69	>84	Time (min)
	99202	99203	99204	99205	+99417	+99417 (x2)	E/M code

An additional shorter (15-minute) prolonged service code (99417) can be reported when the visit is based on time and after the total time of the highest-level service (i.e., 99205 or 99215) has been exceeded. To report a unit of 99417 in addition to 99205 or 99215, you must attain 15 minutes of additional time. Do not report 99417 for any additional time increment of less than 15 minutes.

CMS does not cover CPT code 99417 for prolonged services. Rather, healthcare professionals should use Healthcare Common Procedure Coding System (HCPCS) code G2212 for prolonged services for Medicare patients.

Coding by time is very straightforward. However, it is to your benefit to learn how to code outpatient visits based on the complexity of your medical decision-making instead of relying just on time. The time it takes to complete a high-level medical-decision office visit might be less than the time required to bill for the same visit level based on time. Therefore, having a good understanding of how to appropriately document a visit to code and bill based on the complexity of your medical decision-making can result in a higher level of compensation.

Coding Based on your Medical Decision-Making

As we learned above, you can determine your outpatient E/M code based on Medical Decision-Making (MDM) or total time on the date of the encounter. When coding based on MDM, there are four types of MDM to choose from: straightforward, low, moderate, and high. Each one of them correlates to a visit level 99202-5/99212-5 (see Table 3). There are three key components or elements to consider in selecting the MDM level: problem complexity, management risk, and data (see table 4). Only two out of three elements must be met to reach a MDM level of complexity. For example, if your documentation for the visit has minimal or no data reviewed, but it does have a moderate number and complexity of problems addressed and a moderate risk from additional diagnostic testing or treatment; then this qualifies as a moderate level of MDM and you can select the 99204 or 99214 code depending on if the patient is new or established (see table 6).

Note that this also a simplification of the old guidelines. Before, a new patient must have met or exceeded all of the three key components required to qualify for a particular level of E/M service, while an established patient must have met only two of the three. Now the number of elements required for old and new patients is the same.

Level of MDM	E/M Code	Problem Complexity
N/A	99211	Seen by the nurse
Straightforward	99212/99202	Self-limited
Low	99213/99203	Stable, uncomplicated, single problem
Moderate	99214/99204	Multiple problems or significantly ill
High	99215/99205	Very ill

Level of MDM	Problem Complexity	Management Risk	Data
Straightforward	Minimal	Minimal	Minimal or none
Low	Low	Low	Limited
Moderate	Moderate	Moderate	Moderate
High	High	High	Extensive

Medical decision-making depends on three elements:   

1. Number and complexity of problems addressed at the encounter
2. Amount and/or complexity of data to be reviewed and analyzed
3. Risk of complications and/or morbidity or mortality of patient management

There are subtle but significant changes in the definitions of these three elements compared to the previous guidelines. The switch was made from diagnoses to problems, data now are expected not only to be reviewed but also to be analyzed, and the risks of complications, morbidity, or mortality are derived from the management of the patient instead of from the patient’s problem itself. See table 5 below.

Old Medical Decision-Making Elements

1. The number of diagnoses or management options.

2. The amount and/or complexity of data to be reviewed (medical records, diagnostic tests).

3. The risk of significant complications, morbidity, and/or mortality associated with the patient’s problem(s).

Level of MDM	Problem Complexity	Management Risk	Data
Straightforward	Minimal	Minimal	Minimal or none
Low	Low	Low	Limited
> Moderate <	Moderate	Moderate	Moderate
High	High	High	High

Let’s review each element of medical decision-making in detail.

1. Number and Complexity of Problems Addressed at the Encounter

This element is probably the most important one. It can be classified as minimal, low, moderate, or high. This classification is based on the number of the problem(s) addressed at the encounter and their complexity (e.g., a chronic illness with severe exacerbation is more complex than a stable chronic illness). The following are examples of each level of complexity.

Minimal complexity

• One self-limited or minor problem (e.g., cold, insect bite, tinea corporis).

Low complexity

• Two or more self-limited or minor problems.
• One stable chronic illness (e.g., well-controlled diabetes or hypertension, cataract, benign prostatic hyperplasia). An unstable condition is a condition that is not at goal and poses an increased risk of morbidity without treatment. 
• One acute, uncomplicated illness or injury (e.g., cystitis, allergic rhinitis, simple sprain).

Moderate complexity

• One or more chronic illnesses with exacerbation, progression, or side effects of treatment.
• Two or more stable chronic illnesses.
• One undiagnosed new problem with uncertain prognosis (e.g., breast lump.). This problem could represent high risk of morbidity without treatment.
• One acute illness with systemic symptoms (e.g., pyelonephritis, colitis, pneumonia).
• One acute complicated injury. (e.g., head trauma with brief loss of consciousness).

High complexity

• One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment (e.g., myocardial infarction, pulmonary embolism, severe respiratory distress).
• One acute or chronic illness or injury that poses a threat to life or bodily function (e.g., multiple trauma).

To help avoid any confusion when determining the complexity of a problem, the AMA published a document with the coding guidelines changes that provide detailed definitions related to the MDM elements that have a more clinical intuitive context. It’s a good reference to use when there is a need for clarification.

2. Amount and/or Complexity of Data to be Reviewed and Analyzed

There are three data 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 an external physician or other qualified health-care professional or appropriate source.

This element is in our opinion the most complex as it has many variables you need to calculate. It is probably the least important to remember. If you ever need to calculate your MDM level based on data, make sure you reference the above-mentioned AMA document (see Table 2 on page 7). 

The takeaway point is that you should document any time you review and analyze the following data:

• Order or review a test.
• Review a note from an external source.
• Obtain history from an independent historian because the patient is unable to provide a complete or reliable story.
• Independent interpretation of a test. In other words, you interpret a test by yourself (e.g., you read an x-ray and document the interpretation on your note before the official read and interpretation by the radiologist).
• Discussion of management or test with another health-care professional (e.g., a specialist or external health-care provider) or appropriate source (e.g, a teacher, lawyer, parole officer, case manager.

3. Risk of Complications and/or Morbidity or Mortality of Patient Management

This element in combination with the problem number/complexity is usually the de facto duo used to calculate the MDM level. The element has four levels: minimal, low, moderate, and high. Each level has a direct correlation to the degree of risk of morbidity from additional diagnostic testing or treatment. For example, no treatment will have minimal risk, over-the-counter drug should be low risk, management using a prescription drug or whether or not a patient should have surgery might be considered moderate risk, while deciding that the appropriate management for a patient in your office is to have emergent surgery or hospitalization should be considered as a high-risk management as there usually is a high risk of complications and/or morbidity or mortality in such given cases.

Summary

If all this information is too confusing, just use your common sense when deciding your level of decision-making. You can use the following rules of thumb. 

StatNote’s Rules of Thumb for Outpatient E/M Coding

1. If it only needs a bandaid, then code a Straightforward 99212/99202.
2. If all it takes is a Tylenol, then code a Low 99213/99203.
3. If you need to send a prescription drug, then code a Moderate 99214/99204.
4. If you need to call 911 to take them to the hospital, then code a High 99215/99205.

You might also find our app helpful. E/M coder is a straightforward outpatient billing reference tool that will help you find the right E/M code for your outpatient visit. Hope you find it useful.

Discover Chartnote – We are passionate about preventing physician burnout by decreasing the burden of medical documentation.

About Chartnote

Chartnote is revolutionizing medical documentation one note at a time by making voice-recognition and thousands of templates available to any clinician. We know first-hand that completing notes while treating patients is time-consuming and an epic challenge. Chartnote was developed as a complementary EHR solution to write your SOAP notes faster. Focus on what matters most. Sign up for a free account: chartnote.com

Posted on: January 1, 2021, by : Gerardo Guerra Bonilla