Physicians and other practitioners who are paid under the Medicare Physician Fee Schedule bill for common office and other outpatient visits for evaluation and management (E/M) services use a set of Current Procedural Terminology (CPT)* codes that distinguish visits based on the level of complexity, site of service, and whether the patient is new (CPT codes 99202–99205) or established (CPT codes 99211–99215).
For the first time since its introduction in 1992, the office/outpatient E/M CPT code set has been extensively revised for 2021. This column addresses frequently asked questions about the new office/outpatient E/M reporting guidelines.
How have reporting guidelines for office/outpatient E/M visit codes changed?
In 2021, office/outpatient E/M codes no longer require documentation of a detailed history and exam. Code selection is based on the level of medical decision-making (MDM) or total time spent on the date of the patient encounter, and each service includes a “medically appropriate history and/or examination.”
Do these new guidelines apply to other E/M codes, such as those for consultation services?
For 2021, only the office/outpatient E/M codes 99202–99215 have been revised to allow reporting either using MDM or total time. The 1995/1997 documentation guidelines still apply for all other E/M codes, including consultation codes.
Can MDM and time be used together to select the level of an office/outpatient E/M visit?
No, only one method—either MDM or total time—may be used to select the level of office/outpatient E/M visit code for a single patient encounter. However, you do not need to use the same method for all visits. Surgeons will likely use MDM for code selection for most patient encounters and use total time for code selection to account for a small subset of visits that require low-level MDM but involve extensive time because of extenuating circumstances (for example, language barriers or food or shelter insecurities).
What activities count when reporting an office/outpatient E/M visit using time? May I include time spent by my nurse practitioner or physician assistant when selecting a code level?
All face-to-face and non-face-to-face time of both the physician and qualified health professional (QHP) related to the patient encounter on the day of encounter applies when reporting an office/outpatient E/M visit using time. This includes documentation of the visit in the electronic health record, review of imaging, and consultation with external physicians, among other types of work. Time for clinical staff (such as nurses, medical assistants) may not be included in the physician/QHP total time.
What if I use MDM to select a level of code to report an office/outpatient visit? Is this based solely on work performed on the day of the encounter?
When using MDM to select the code level, activities that are performed on days before or after the office visit that are directly related to the encounter, such as speaking with a radiologist about an imaging report, may be counted.
If a patient newly diagnosed with cancer is referred to a surgeon for possible resection surgery, and the surgeon decides that surgery is not indicated after evaluation of the patient, is it still considered a decision for surgery under the “risk” element of MDM?
Yes, this scenario applies to the MDM element “risk of complications and/or morbidity or mortality of patient management,” which includes both possible management options selected, as well as those considered but not selected after shared decision-making with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care, such as a skilled nursing facility or home care. Shared MDM involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options.
May I report an office/outpatient E/M code and a procedure code if a procedure is performed on the same day?
The rules for reporting an E/M code and procedure code on the same day have not changed. Modifier 25 may be appended to the E/M code to indicate that on the day a procedure was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. If one uses time rather than MDM to justify the level of E/M service billed, the time to prepare and perform the procedure cannot be considered in the calculation of total time.
Does “major” and “minor” surgery refer to a global period (0-, 10-, 90-day) or the place of service (office, outpatient, inpatient)? If the Centers for Medicare & Medicaid definition of major surgery is a code with a 90-day global period, does this mean a “major procedure” in the MDM risk table only applies to 90-day global codes?
The terms “major” and “minor” in MDM Element 3 (Risk) are unrelated to the global period of a code. The CPT guidelines for code level selection and definitions for major and minor surgery specifically describe the intent of these terms. Medicare refers to major and minor surgery in the context of the amount of postoperative work that is bundled for global package payment. When estimating risk for the determination of the level of MDM, major and minor are based on the common meaning as interpreted by trained clinicians and not based on a global payment package assignment. These terms are not defined by a global payment package classification nor are they defined by the type of anesthesia administered.
Where can I get more information about the 2021 office/outpatient E/M visit coding changes?
The following resources are available:
- ACS Office/Outpatient E/M Coding Changes Resource Center: The American College of Surgeons (ACS) Division of Advocacy and Health Policy (DAHP) has created a robust set of online tools to help surgeons and their practice staff navigate these changes. Such tools outline the new office/outpatient E/M code descriptors, guidelines for reporting MDM and time, documentation requirements, frequently asked questions, and other information related to the revised coding structure (see Figure 1). These free resources, including a downloadable coding changes booklet, are available on the ACS website.
- Webinars: The ACS hosts a series of complimentary webinars in coordination with the ACS General Surgery Coding and Reimbursement Committee to share insights from surgeons actively implementing the office/outpatient E/M coding changes. This Major Changes for 2021 Office E/M Coding webinar series includes the following: Part 1: A Surgeon’s Guide to Prepare for New Guidelines and Avoid Claims Denials, and Part 2: Implementation Tips. Additional parts of the series are forthcoming. The webinar recordings and related slide decks are available within the ACS Office/Outpatient E/M Coding Changes Resources Center.
- On-demand coding courses: The ACS collaborates with KarenZupko & Associates (KZA) in offering four on-demand coding courses that provide the tools necessary to increase revenue and decrease compliance risk. These courses are an opportunity to sharpen your coding skills, and the on-demand feature allows starting and stopping when convenient. You also will be provided online access to the KZA alumni site, where you will find additional resources and frequently asked questions about correct coding. The 2021 on-demand coding courses and available continuing medical education (CME) credits are provided in Table 1. Additional information about the courses and registration can be accessed online.
- ACS Coding Hotline: As part of the ACS’ ongoing efforts to support Fellows and their practices in submitting clean claims and receiving proper reimbursement, a coding consultation service—the ACS Coding Hotline—has been established that Fellows and their practice staff may contact with questions related to coding and billing. ACS Fellows are offered five free consultation units (CUs) per calendar year. One CU is a period of up to 10 minutes of coding services time. Take the following steps to take advantage of the hotline:
- Access the ACS Coding Hotline website.
- Fill out the specified contact information, including your ACS membership number. Note that practice staff may submit questions to the Coding Hotline on behalf of an ACS Fellow by using the Fellow’s membership number.
- Describe your question(s) in the text box, attach any supporting Health Insurance Portability and Accountability Act-compliant documentation (for example, de-identified operative notes or claims denials), and submit.
- A member of the Coding Hotline staff will reach out to you via e-mail to answer your question(s).
*All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.