• Coding for Evaluation & Management Services

    Evaluation and management (E/M) codes are at the core of most family physician practices. Family physicians and other qualified health professionals (QHPs), such as nurse practitioners or physician assistants, can maximize payment and reduce the stress associated with audits by understanding how to properly document and code for E/M services.

    E/M services represent a category of Current Procedural Terminology (CPT) codes used for billing purposes. Most patient visits require an E/M code. There are different levels of E/M codes, which are determined by the complexity of a patient visit and documentation requirements.

    The Primary Care Add-on Code G2211 were not implemented on January 1, 2021 as expected due to Congressional action. All other anticipated payment, coding and documentation changes for 2021 are expected to go into effect as planned.

    Changes Effective in 2021**

    In response to advocacy from the AAFP and other medical specialty societies, the CPT Editorial Panel revised the E/M documentation and coding guidelines for office visits effective January 1, 2021. These fundamental changes are intended to reduce administrative burden and increase the amount of time physicians spend caring for patients. The Centers for Medicare & Medicaid Services (CMS) accepted the CPT changes and increased the relative values for office visit E/M codes and created a primary care add-on code as part of the Medicare physician fee schedule. 

    Here are highlights of key changes:

    History and physical exam elements eliminated (when not appropriate): The patient history and physical exam elements are no longer components of E/M level code selection. Physicians should still document the history and physical exam as medically appropriate. These elements may still be necessary for clinical practice, professional liability (i.e., malpractice) reasons, and quality measurement.

    99201 is no longer a valid code: CPT code 99201 has been deleted and is no longer available as a CPT code selection.

    1995/1997 E/M documentation guidelines have been replaced by medical decision-making (MDM) or total time for office visit E/M codes: The 1995 and 1997 E/M documentation guidelines no longer apply to office visit E/M codes. Physicians may select the level of office visit using either total time or MDM. The definition of total time in CPT office visit code selection is expanded to include all physician or QHP time (both face-to-face and non-face-to-face) spent in care of the patient on the day of the encounter. The elements of MDM have been updated. See below for more details on selecting E/M codes by total time or MDM.

    **Please note, these changes apply only to office visit and outpatient E/M services (CPT codes 99202-99205 and 99211-99215).

    Selecting E/M Codes by Total Time

    Total time may be used alone to select the appropriate code level for office visit E/M services (99202-99205, 99212-99215). A key change in the new guidelines is the updated definition of time. Time may be used to select the level of service regardless of whether counseling dominated the encounter. The revised definition of time consists of the cumulative amount of face-to-face and non-face-to-face time personally spent by the physician or other QHP in care of the patient on the date of the encounter. It includes activities such as:

    • Preparing to see the patient (e.g., review of tests);
    • Obtaining and/or reviewing separately obtained history;
    • Ordering medications, tests or procedures;
    • Documenting clinical information in the electronic health record (EHR) or other records; and
    • Communicating with the patient, family, and/or caregiver(s).

    Time spent in activities normally performed by clinical staff (e.g., time spent by nursing or other clinical staff collecting a patient’s history) should not be counted toward total time. Furthermore, time spent on a date other than the date of service should not be counted toward total time. For example, completing documentation on the day after the encounter would not be counted toward the total time when selecting the level of service for the encounter. Finally, time spent on services that are separately reportable (e.g., independent interpretation and reporting of test results, tobacco cessation counseling) should not be included in total time calculations.

    Each code now has a specific time range. Physicians should ensure they document the total time spent on the date of the encounter in the patient’s medical record. Physicians should avoid documenting time ranges and instead document specific total time spent on activities on the date of the encounter.

    CPT Code Time Range

    99202

    15-29 minutes

    99203

    30-44 minutes

    99204

    45-59 minutes

    99205

    60-74 minutes

    99212

    10-19 minutes

    99213

    20-29 minutes

    99214

    30-39 minutes

    99215

    40-54 minutes

    Prolonged Services

    Per CPT, if the total time on the date of service exceeds the minimum time of the maximum level of service (i.e., 99205 or 99215) by at least 15 minutes, physicians can bill for prolonged services using the new add-on CPT code 99417 (“prolonged office or other outpatient evaluation and management service(s) [beyond the total time of the primary procedure which has been selected using total time], requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time”). CPT code 99417 can be billed in 15-minute increments and can only be billed when total time is used to determine the level of service. CPT code 99417 should not be billed for increments of less than 15 minutes. Physicians should not bill CPT code 99417 with the following CPT codes: 99354, 99355, 99358, 99359, 99415, or 99416.

    CMS does not cover CPT code 99417 for prolonged services. Rather, physicians should use Healthcare Common Procedure Coding System (HCPCS) code G2212 for prolonged services for Medicare patients when the total time on the date of service exceeds the maximum required time of the primary procedure code that has been selected using total time on the date of the primary service. HCPCS code G2212 should not be reported for increments of less than 15 minutes. Physicians should not bill HCPCS code G2212 with the following CPT codes: 99354, 99355, 99358, 99359, 99415, or 99416.

    Selecting E/M Codes by MDM

    MDM is the reflection of complexity in establishing a diagnosis, assessing the status of a condition and/or selecting a management option. The revised MDM table focuses on the cognitive work related to the diagnosis and assessment of a patient’s condition. Physicians should document the thought processes, including treatment options considered but not selected, that contribute to their diagnosis and treatment plan for the patient. To qualify for a level of MDM, two of the three elements for that level must be met or exceeded.

    Number and complexity of problems addressed at the encounter

    The 1995/1997 MDM elements relied on the number of diagnoses without addressing the complexity of the patient’s condition. The revised MDM table accounts for the complexity of problems addressed during the encounter, rather than just the number of diagnoses. Diagnoses that are not made or addressed during the encounter and that do not contribute to the physician’s MDM process should not be included in selecting the level of MDM.

    Amount and/or complexity of data to be reviewed and analyzed

    Physicians should include labs and tests that were pertinent to the encounter and contributed to the MDM for the encounter. Data that did not impact the assessment and treatment of the patient does not need to be copied into the note. Labs/tests are defined by their corresponding CPT codes. As such, a panel would be considered one lab for the purposes of this category.

    Risk of complications and/or morbidity or mortality of patient management

    A variety of elements contribute to the risk of complications and/or morbidity or mortality of patient management. Examples include but are not limited to prescription management, social determinants of health, and decisions regarding surgery. Options considered but not selected should be appropriately documented and included when determining the risk.

    The table below outlines the levels and elements of MDM. The full table is available here.

    CPT Codes

    Levels of MDM

    Number and complexity
    of problems addressed

    Amount and/or complexity of
    data to be reviewed and analyzed

    Risk of complications and/or
    morbidity or mortality

    99202, 99212

    Straightforward

    Minimal

    Minimal or None

    Minimal

    99203, 99213

    Low

    Low

    Limited

    Low

    99204, 99214

    Moderate

    Moderate

    Moderate

    Moderate

    99205, 99215

    High

    High

    Extensive

    High


     

    Primary Care Add-on Code (G2211)

    The Primary Care Add-on Code G2211 will not be implemented on January 1, 2021, as expected due to Congressional action. All other anticipated payment, coding and documentation changes for 2021 are expected to go into effect as planned.

    Increased Values

    Medicare has increased the relative value units of office visit E/M codes. Physicians can look up the new values and allowed amounts using the Medicare Physician Fee Schedule Lookup Tool.

    Private Payers

    The updated coding and documentation guidelines apply to private payers, not just Medicare. However, payers vary on their acceptance of the primary care add-on code. Additionally, adoption of the increased values will vary based on a physician’s contract with the payer. Physicians should contact their local provider relations representatives to discuss incorporating the increased values into their contracts. The “Questions to Ask Your Payers” resource listed below can be used as a guide for these conversations.

     

    2021 Office Visit Evaluation and Management Documentation Resources: 

    The Primary Care Add-on Code G2211 will not be implemented on January 1, 2021 as expected due to Congressional action. All other anticipated payment, coding and documentation changes for 2021 are expected to go into effect as planned.

    The following resources are available to AAFP members. Click to log in and access them.

    1. A Checklist for Solo and Independent Physicians - This checklist is designed specifically to help small, solo, and independent practices understand steps to take throughout 2020 to ensure readiness in 2021. The AAFP will provide additional resources to help practices navigate the checklist.
    2. A Checklist for Employed Physicians - This checklist offers steps employed physicians can take to better understand their employer's training plan and ensure their employment contracts are updated appropriately.
    3. Practice Training Outline - This sample training outline will help practices implement the updated E/M guidelines. It can be used as a guide to ensure physicians and staff understand the key concepts and documentation changes.
    4. Questions to Ask Your Vendors - The updated documentation guidelines will affect multiple aspects of a practice, including its EHR. The AAFP has developed a set of important questions to help physicians gather key information on their vendors’ plans.
    5. Questions to Ask Your Payers - This resource can be used as a guide for conversations with payers. Practices will need to understand the impact on their contracts, as well as what training/support the payer plans to offer. 
    6. Template Payer Letter - The AAFP will continue to advocate for uniform adoption of changes across all payers, and members can help by contacting the payers with which they work. This template can be used to send a letter to private payers to encourage them to adopt the same payment policy changes for E/M codes.
    7. Talking Points for Employed Physicians - Physicians can use this resource to determine whether they should have a conversation with their administrator about how the revaluation of codes will impact payment or if a contract amendment is appropriate for them. 
    8. 2021 Office Visit E/M Vignettes Module - This resource allows physicians to practice coding various scenarios using the new guidelines.
    9. 2021 Office Visit E/M Guidelines ModuleThis resource walks physicians through the new E/M coding guidelines.

    AAFP Coding Reference Cards: 2021 Office Visit Evaluation & Management Coding & Documentation: New office visit evaluation and management coding guidelines took effect January 1, 2021. Physicians can ensure they receive accurate payment with the AAFP’s new E/M Reference Cards.


    Family Medicine Practice Hack Video - E/M Coding

     

    The Primary Care Add-on Code G2211 were not implemented on January 1, 2021 as expected due to Congressional action. All other anticipated payment, coding and documentation changes for 2021 are expected to go into effect as planned.

    Watch this Practice Hack video to learn how to use the resources above and prepare for the E/M coding changes.

    Stay tuned for additional videos in the Practice Hack series that will provide you with tips and tricks to help you more easily manage your practice.

    Additional Resources: