Evaluation and management (E/M) codes are at the core of most family physician practices. Family physicians and other qualified health professionals can maximize payment and reduce the stress associated with audits by understanding how to properly document and code for E/M services.
Evaluation and management services are a category of CPT codes and are used for billing purposes. The majority of 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.
In response to advocacy from the AAFP and other medical specialty societies, CMS has revised the E/M documentation and coding guidelines, with changes beginning January 1, 2021. These fundamental changes (www.ama-assn.org) are intended to reduce administrative burden and increase the amount of time physicians spend caring for patients. CMS will also increase the relative values for office visit E/M codes.
Though the changes don't go into effect until 2021, practices should begin preparing now. Here are highlights of key changes being implemented.
History and physical exam codes eliminated (when not appropriate): The patient history and physical exam elements will no longer be components of E/M level code selection. These elements may still be required in relationship to malpractice and quality measures. An understanding of all external documentation guidelines will be necessary before excluding these elements.
99201 is no longer a valide code: CPT code 99201 will be deleted and will no longer be available as a CPT code selection.
1995/1997 guidelines will be replaced by medical decision making (MDM) or total time: The 1995 and 1997 guidelines will no longer apply. Physicians will have the option to select the level of visit using either total time or medical decision making (MDM). The definition of total time in CPT code selection is expanded to include all 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.
Selecting E/M codes by total time - Total time may be used alone to select the appropriate code level for the office or other outpatient E/M services codes (99202-99205, 99212-99215). Total time is the cumulative amount of time spent in care of the patient on the date of the encounter, inclusive of face-to-face and non-face-to-face time spent by the physician and/or other qualified health care professionals. It includes activities such as review of tests; obtaining and/or reviewing separately obtained history; ordering medications, tests or procedures; documentation of clinical information in the electronic health record (EHR) or other records; and communication with the patient, family, and/or caregiver(s).
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 table below outlines the levels and elements of MDM.
|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|
There are two sets of E/M guidelines: 1995 and 1997. The main difference between the 1995 and 1997 guidelines is the examination component. The 1995 guidelines allow more latitude for a detailed exam, by merely stating that two to seven body area or organ systems** may be addressed and documented. To meet a detailed exam using the 1997 guidelines, a physician must document upwards of 12 “bullets” that may or may not be pertinent to the CC at each encounter. Physicians should use one version of the documentation guidelines for an encounter, not a combination of the two.
**Verify with your local Medicare Administrative Contractor and other payers to determine the amount and complexity of the exam components required.
Effective January 1, 2019, Medicare allowed physicians to document, review, and verify any history entered into medical record by ancillary staff or the beneficiary in lieu of re-entering that information. For established patients only, history and examination already contained in the medical record does not need to be re-entered. Rather, the physician may document what has changed and pertinent items that have not changed since the last visit.