2021 is now here and, with it, comes changes to how physicians must document for and code patient office and outpatient visits. For the first time since the implementation of office/outpatient visit E/M CPT code set in 1992, the Centers for Medicaid and Medicare Services (CMS) has instituted extensive changes to the coding criteria.
There is some reason to celebrate. Say goodbye to any unnecessary 14-point Review of Systems; the motivation behind these revisions was to address documentation burden and note-bloat. Now you only need to document a medically appropriate history and/or examination.
How to Determine Which CPT Code to Bill
CMS is now allowing the physician to choose to evaluate visits by either Time or Medical Decision Making (MDM).
Time
If you choose to code by time, note that, unlike previous years, time is no longer limited to face-to-face time spent with the patient. Time-based coding determinations now account for the sum of both face-to-face and non-face-to-face services of the physician or QHP on the date of the encounter and does not require counseling and/or care coordination to dominate the service.
To determine your time-based code, use the table below.
Medical Decision Making (MDM)
Using MDM to determine the level of exam requires 2 of 3 components (problems, data, and risk) to meet or exceed the level of decision making for the code. See the table below.
Impact on MIPS
The 2021 E/M changes have no direct impact on 2021 MIPS. Although these E/M changes now only require a medically appropriate H&P, be sure to continue to document and capture everything you need for your selected MIPS measures.
Additional Resources
American Medical Association:
American Academy of Dermatology: Coding Resource Center
American Academy of Ophthalmology: Landing Page for 2021 E/M Coding Resources
American College of Surgeons: 2021 E/M Office and Outpatient Visit Coding Resources
American Society of Clinical Oncology: 2021 Guide to Selecting an E/M Code Based on MDM
CPT is a registered trademark of the American Medical Association. Copyright 2020 American Medical Association. All rights reserved.