Starting in 2021, the guidelines for outpatient E/M coding changed, and the need for a certain number of history and exam elements to help determine a visit level was eliminated. Now, providers should document a medically appropriate history and exam, and the selection of the visit level is driven by time or medical decision-making.
This post explores these service levels and how the 2021 changes affect how providers bill for the care they provide. Understanding how to code for services rendered empowers providers and healthcare practices to receive appropriate compensation, reduce claims denials, and maintain compliance with payers and healthcare regulations.
Read on to explore outpatient E/M coding changes so your team can accurately and effectively bill your payers.
Level of Service Based on Time
For coding purposes, time is considered the total time that includes both face-to-face and non-face-to-face time on the day of the encounter.
Included in Total Time
The following points are taken from the CPT® manual maintained by the AMA and are elements included in the total time:
- Preparing to see the patient (e.g., reviewing external test results)
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient, family, or caregiver
- Ordering medications, tests, or procedures
- Referring and communicating with other health care professionals (when not separately reported)
- Documenting clinical information in the electronic or other health records
- Independently interpreting results (not separately reported with a CPT® code) and communicating results to the patient, family, or caregiver
- Care coordination (not separately reported with a CPT® code)
Not Included in Total Time
The following elements are not included in the total time:
- Performance of other services that are reported separately
- Teaching that is general and not limited to the discussion that is required for the management of a specific patient
Below are tables that showcase the time allowed by each CPT® code:
|New Patient||Time (minutes)|
|Established Patient||Time (minutes)|
Prolonged Visit Codes
When the total time on the date of service extends beyond the times listed above for codes 99205 and 99215 by at least 15 minutes, a prolonged service code may be added, and it can be billed in 15-minute increments.
|Prolonged Service Code||Definition|
|CPT®||99417||Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time|
|HCPCS (CMS)||G2212||Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact|
Level of Service Based on Medical Decision Making
In the section above, we explored time-based coding. Now we’ll walk through levels of services based on medical decision-making.
The three elements of medical decision-making include:
- The number and complexity of problems that are addressed during the encounter
- The amount and/or complexity of data to be reviewed or analyzed
- Data would consist of information that must be reviewed, obtained, ordered, and analyzed for the encounter
- The risk of complications and/or morbidity or mortality of the patient management
The levels of medical decision-making are broken down into four types:
- Low complexity
- Moderate complexity
- High complexity
Below is a graph displaying the levels of service based on medical decision-making.
|MDM Level||Number and complexity of problems addressed||Amount and/or complexity of data to be reviewed or analyzed
|Risk of complications and/or morbidity or mortality of the patient management|
|Straightforward||Minimal||Minimal or none||Minimal|
Two out of three elements from the table must be met or exceeded to determine a level of service for an encounter.
For example, a provider may address multiple problems during a visit; however, there is limited data, and the risk is low. In this scenario, the medical decision-making level would qualify as low.
The following table below breaks down the number and complexity of problems addressed:
|99202/99212||Minimal||One self-limited or minor problem|
|99203/99213||Low||Two or more self-limited or minor problems or one stable, chronic illness or one acute, uncomplicated illness or injury|
|99204/99214||Moderate||One or more chronic illnesses with exacerbation, progression, or side effects or treatment; or two or more stable, chronic illnesses; one undiagnosed new problem with uncertain prognosis; or one acute illness with systemic symptoms or one acute uncomplicated injury|
|99205/99215||High||One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment, or one acute or chronic illness or injury that poses a threat to life or bodily function|
While every patient encounter and diagnosis are unique and nuanced, general examples can be helpful when gauging MDM levels. You can find examples for each level below:
|99202/99212||Minimal||Common cold in an otherwise healthy patient|
|99204/99214||Moderate||A patient with a history of hypertension, which is poorly controlled, who requires changes to blood pressure medications|
|99205/99215||High||Severe exacerbation of COPD who is admitted to the hospital
Coding Updates and Your Practice
Understanding outpatient E/M coding guidelines is essential for your practice to thrive. Accurate and compliant billing, claims fulfillment, and appropriate compensation requires an up-to-date and thorough knowledge of the new outpatient E/M coding guidelines.
However, keeping up with these changes and submitting all patient claims correctly the first time can be challenging. Providers’ primary focus is patient care. As a result, coding and claims management can fall by the wayside.
At Larsen Billing, our focus is appropriately managing your billing, coding, credentialing, and contract negotiations so you can devote your time to the things that matter most. Reach out to our team today to learn how Larsen Billing’s specialized medical billing solutions can help your practice thrive.