The year 2021 marks a historic change in the coding world for outpatient office visits, with the first major revision to the CPT evaluation and management (E/M) codes in more than 20 years taking effect. The most impactful change, which was effective Jan. 1, is to the E/M Office or Other Outpatient Services codes and guidelines (code range 99202–99215). This article addresses the who, what, when, where, why, and how of these significant changes.

The changes allow physicians to focus on decision making and treatment over a surplus of unnecessary and unrelated documentation. The changes may prove to be more valuable than the expanse of repetitive data that seemed to have had no real impact on the treatment plan.

Why was this change initiated, and who drove the changes?

In an effort to reduce the administrative burden and redundant documentation requirements for outpatient office visits, the American Medical Association (AMA) CPT Editorial Panel worked with numerous specialty societies and other stakeholders to simplify and streamline documentation requirements for reporting E/M office or outpatient service codes 99202–99215. Code 99201 was deleted.

What changes were made and when?

Effective Jan. 1, the significant changes to the code descriptors and accompanying guidelines for codes 99202–99215 remove the tallying of key components and instead allow providers to select E/M levels based on either medical decision making (MDM) or time only.

Time now also includes all nonface-to-face activities performed on the same date of service. Only a medically necessary history and/or exam must be documented and will no longer be used to determine the appropriate code selection.

Who must adhere to these changes?

The Centers for Medicare & Medicaid Services (CMS) finalized a policy to adopt the CPT revised codes and guidance set forth in the 2021 CPT code set issued by the AMA CPT Editorial Panel. These revised CPT codes and guidelines affect all payers, not just Medicare. Because the CPT code set has been adopted as the nation’s standard medical data code set, HIPAA requires that all health plans use the most recent version of the medical data code set. Therefore, when reporting any Office or Other Outpatient E/M services, the revised 2021 CPT code set must be utilized.

How will these revised codes be reimbursed?

On Dec. 1, 2020, CMS released the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule (CMS-1734-F). Table 1, derived from the MPFS CY 2021, lists the finalized work relative value units for 2021 in comparison to 2020 for codes 99202–99215.

It is important to note that these code and guideline changes apply only to Office or Other Outpatient E/M services performed and do not apply to consultation, inpatient, nursing home, or any other E/M services.

To ensure that the documentation requirements necessary are captured to report the correct levels of E/M services for new and established patients, it is important to confirm that your electronic health records and billing software systems are updated to reflect these substantial changes.

For more information on 10 key items to discuss with your software vendors, read the September 2020 AAOS Now article titled “Evaluation and Management Changes Are Coming Soon.”

Where are in-depth resources?

AAOS Now has published several articles on this topic, and AAOS has presented a two-part webinar series that goes over the changes in great detail.

To learn more, read the following AAOS Now articles online at www.aaosnow.org:

• April 2020 issue: “Major Changes Are Coming to E/M Visits in 2021: Will You Be Ready?” which addresses the scope of guideline changes, including detailed discussion on the amount and complexity of data to be reviewed and analyzed.
• August 2020 issue: “The Devil Is in the Details,” which discusses the reconfiguration of MDM in the 2021 CPT guidelines, as well as presents examples of reporting based on MDM.
• November 2020 issue: “Is Time on Your Side in 2021?” which details how to report these codes based on the new time guidelines.

To view the AAOS OnDemand webinars, visit https://learn.aaos.org/diweb/home. Select Evaluation & Management (E/M) Changes – What you need to know for 2021 – Part I to learn about the history of E/M services guidelines, the specific changes, and how to report the correct level of E/M services accurately according to the new reporting guidelines. Part II covers documentation requirements for the new 2021 E/M guidelines, including case study examples. Member login is required.

CPT is a registered trademark of the AMA.

Michelle Abraham, MHA, CCS-P, is the coding and reimbursement coordinator for the AAOS Office of Government Relations.