2021 E&M Code Changes

Nicoleta Rahovan, Lead Coder, CPC, CANPC


 Dear Doctor,

We would like to inform you that there are big changes coming for E&M in 2021. These changes relate only to new and established office and outpatient visit codes 99202-99215 (POS 11,19, and 22). These type of visits can be coded based on MDM or total time. In order to be coded to the most accurate level we encourage you to document on your reports the total time spent on the date of the encounter. Here is a list of what can represent time spent on date of service:

  • Preparing to see patient (e.g., review of tests).
  • Obtaining and/or reviewing separately obtained history.
  • Performing a medically appropriate examination and/or evaluation.
  • Counseling and educating patient/family/caregiver.
  • Ordering medications, tests or procedures.
  • Referring and communicating with other health care professionals (when not separately reported).
  • Documenting clinical information in electronic or other health record.
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
  • Care coordination (not separately reported).

Documentation requirements:

  • Documentation must clearly indicate nature of services performed (“I spent an hour on the phone after patient’s appointment is not sufficient”).
  • Documentation must indicate amount of time for the separately reported services was not included in total time for the E/M level selection (If reporting both and E/M service by the time and minor procedure documenting “total patient care time 30 min” is not sufficient).
  • Documentation must support medical necessity of time spent on patient encounter (If a 50 min. visit is documented and billed as 99215 with a diagnosis of cough with no other information is not sufficient).