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Evaluation & Management (E&M) 2021 Updates

2021 Updates for Evaluation & Management (E&M) (aka office visit) coding & documentation

Starting 2021 marks the first major overhaul of guidelines for documenting & selection for Evaluation & Management (E&M) codes

These codes are used to represent your office visits (evaluation & management) of your patients

New patient codes range from 99202-99205

*99201 deleted as of January 1, 2021

*New patient means the patient has not presented to your practice within the last 3 years

Established patient codes range from 99211-99215

Consultation codes range from 99241-99245

*Medicare and various commercial medical insurers no longer accept this code set, use new & established E&M codes only

*A direct referral from other healthcare provider, as well as a follow up letter to that referring provider are required for use of this code set

You may select the level of code based on the total time spent with the patient, or based on the level of medical decision making (MDM)

Below is coding tables to help you choose:

new pt codes

est pt codes

**99211: level 1 established patient E/M code 99211 will still be available, but its code descriptor will not include a time reference in 2021.

What all is included in total time spent?

  • For coding purposes, time for these services is the total time on the date of the encounter
  • Includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s)
  • includes time in activities that require the physician or other qualified health care professional but does not include time in activities normally performed by clinical staff

Activities can include:

  • preparing to see the patient (i.e., review of tests)
  • obtaining/reviewing separately obtained history
  • performing a medically appropriate examination/evaluation
  • counseling and educating the patient/family/caregiver
  • ordering medications, tests, or procedures
  • referring and communicating with other health care professionals
  • documenting clinical information in the health record
  • independently interpreting results and communicating results to the patient/family/caregiver
  • care coordination