CMS has finalized changes to the way office/outpatient E/M codes (99202-99215) will be chosen and documented. Note that the following changes apply only to the office/outpatient E/M services; continue to bill and document as you always have in all other settings.
Quick Guide to 2021 E/M Office/Outpatient Services (99202 – 99215) Coding Changes (.pdf) includes the summary below along with information on the new time ranges, prolonged services codes and a medical decision making table with psychiatric specific examples. The guide can be printed and serve as a handy resource as you adapt to the changes.
As of January 1, 2021, codes for office/outpatient medical evaluation and management (E/M) care can be selected on the basis of the complexity of the medical decision making (MDM) or on the basis of the total time on the date of the encounter.
For psychiatrists who provide E/M services along with psychotherapy, the appropriate E/M code must be determined by the level of the medical decision making, as newly defined. Time cannot be used to determine E/M when adding on psychotherapy.
The revised MDM guidelines are outlined in the Medical Decision Making table of the Quick Guide to 2021 Office/Outpatient E/M Services (99202-99215) Coding Changes which includes psychiatric specific examples as illustrations. The level of MDM should be driven by the nature of the presenting problem on the date of the encounter. Time is not a factor when code selection is done on the basis of MDM.
When billing outpatient E/M on the basis of time, psychiatrists may now use the total time on the date of the service related to the patient encounter, not just the face-to-face time. This includes:
- Preparing to see the patient (e.g., review of test, records)
- Obtaining and/or reviewing separately obtained history
- Performing a medically necessary exam and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests, or procedures
- Referring and communicating with other healthcare professionals (when not reported separately)
- Documenting clinical information in the electronic or paper health record
- Independently interpreting results of tests/labs and communication of results to the family or caregiver
- Care coordination (when not reported separately)
Two new prolonged service codes were created for use when outpatient E/M services exceed each 15 minutes beyond the highest level E/M code (99205, 99215). One is for use with Medicare patients (G2212) and the other is a CPT code (99417). Check with your non-Medicare payers to determine which to use and check the specific requires for use which vary between the two codes.
Documentation has been simplified:
- Code selection based on medical decision making MUST include information pertinent to that element.
- The extent of the history and exam is not considered for code selection, so history and exam should be documented as medically necessary and as needed to provide good clinical care.
- Code selection based on total time MUST include the total time spent on the date of the encounter and a summary of relevant clinical activities.
- The lowest level new patient outpatient E/M code used by non-physicians, 99201 has been eliminated.
We recommend you review the most recent edition of the AMA CPT manual for the full guidance related to the changes to the office/outpatient E/M services and other coding updates.