Practice Perfect 736
A Public Service Announcement: New Evaluation and Management Coding

As you may know, important medical coding changes are set to take effect on January 1, 2021, and these changes will affect all of us. These coming changes will affect the evaluation and management (E&M) codes. The changes are detailed in the American Medical Association’s Code and Guideline Changes document. Click here for the full document. I highly recommend reading the document and watching online information sessions to fully understand the changes, but let’s review the main points to get you started. 

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As a quick review, the current E&M codes (99201-99205, 99211-99215, etc) are used for nonprocedural patient encounters (rather than CPT procedure or Current Procedural Terminology codes that are assigned to actual procedures such as surgery). Different E&M codes are assigned to new versus follow-up patients and the specific code is determined by satisfying certain criteria that were based on bullets from the history and physical, level of decision-making, and time spent counseling and coordinating care. For each code insurance companies would reimburse physicians increasing amounts of money as the code numbers increased. Other E&M codes exist such as for patients in hospitals, but the new code changes will mostly affect the 9920x and 9921x series (office and outpatient codes).

The first major change will be that E&M codes will be determined on medical decision making (MDM) or time and not bullets from history and exam. This will eliminate bullet counting (yay!), but we still need to document the history and exam. How will they do this?

There are four levels of MDM: Straightforward, Low, Moderate, and High

Levels now line up with numbers, including new and follow-up patients.

  • Straightforward: 99202, 99212
  • Low: 99203, 99213
  • Moderate: 99204, 99214
  • High: 99205, 99215
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See the risk table tool to use when determining the level to assign to an encounter. This table is modified from the AMA document.1 There is a lot of information to assimilate, so I recommend taking some extra time and becoming very familiar with the criteria for assigning codes. 

Click on the Table Above to See a Larger Version

Total time (the time the provider spends on the patient during the day of the encounter) can also be used to select the level and is allowed to be used even if there is no counseling or coordination of care. This time includes preparation for the encounter, the encounter itself, and work resulting from the encounter, including documentation. What specifically counts toward total time? Here’s a list2:

  • Reviewing the medical record before the encounter
  • Face-to-face time during the visit itself
  • Communicating care to other family members or other providers
  • Ordering labs, medications, or referrals
  • Calling the patient later to discuss results and further recommendations
  • Documenting the visit in the medical record

This chart, adapted from Millette2, shows the total time allowances for new patients (99202-99205) and established patients (99212-99215). Since most podiatrists will complete their encounters in under 55 minutes, I am leaving out the prolonged services codes. However, in certain complex situations they may still be applicable so don’t forget about them!

Visit Level New Patient Established Visit
2 15 - 29 min 10 - 19 min
3 30 - 44 min 20 - 29 min
4 45 - 59 min 30 - 39 min
5 60 - 74 min 40 - 54 min
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Use 99211 to report time spent supervising clinical staff who provided a face-to-face encounter. In situations where extra time is needed to see a patient, providers should report 99XXX (99354, 99355, 99356) for prolonged services along with the 99202-99215. There is a chart to determine which code to use (with a minimum time if greater than 75 minutes with a new patient and greater than 55 minutes if a follow up patient).

Here are some other details to be aware of:

  1. Providers cannot use procedures performed on the same day as the E&M to calculate the level of complexity. These are considered to be separate.
  2. Code 99201 will disappear entirely.
  3. Pay attention to social determinants of health which are considered moderate risk if they impact a patient’s care (such as homeless, foster care, or abusive relationship).
  4. The number and complexity of the problems addressed in an encounter will be important in determining the coding level.

Desert Foot 2020 Online

Now, by no means is this all you need to know about the new coding changes, and every provider should make themselves as knowledgeable as possible. But I hope this gets you started with the basics so when the New Year arrives, you are ready to adopt the new E&M codes. 

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
  1. CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes. American Medical Association. 2019
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  2. Millette KW. Countdown to the E/M Coding Changes. Fam Pract Manag. 2020 Oct;27(5):29-36.
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