As most providers are aware, the rules/guidelines changed effective 1/1/21.  The changes affect code range 99202 – 99215.

These changes should help reduce the amount of redundant and overwhelming documentation that was required under the old rules for selecting an E/M level of service.  The level of service is now selected by:

1. The level of medical decision making as defined for each service, or
2. The total time spent for that date of service.

Level of Medical Decision Making – (Codes 99202-99215) consist of 3 components:

1.  Problem:  the number and complexity of problems addressed
2. Data:  amount and /or complexity of data to be reviewed and analyzed
3. Risk:  risk of complications and/or morbidity or morality of patient management

When using MDM for code selection, two of the above three elements must be met.  See your CPT manual for additional information. 

Total Time spent – (Codes 99202-99205 and 99212-99215):

When using time as a basis for code selection, use the total time on the date of service only.  Time includes both the face-to-face and non-face-to-face time that is personally spent by the physician and/or other qualified health care professionals on the day of the visit – this includes time in activities that require the physician or other qualified health care professional but not time spent by clinical staff.  Time spent on activities that are separately billable are also not included.  Counseling and coordination of care no longer has to dominate the time spent with a patient when using time for code selection.

Prolonged time codes 99354 – 99359 can no longer be used with the above codes.  New codes 99417/G2212 may be used with 99205 and 99215.  See your CPT code book for additional information.

Medical necessity is still the overarching criteria for the level of service – which includes the decision making process of the care provider in addition to the requirements of the CPT code. 

These changes have added some major confusion to the E/M coding process and it will take some time for everyone to get comfortable with it.  There are many resources out there and some great webinars to help alleviate some that.