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2021 CPT® Evaluation and Management (E/M) Coding Changes Friday, January 08, 2021

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Resources for Physician Practices 

The AMA and the Centers for Medicare & Medicaid Services have completed a major overhaul of evaluation and management (E/M) office visit documentation and coding.  These landmark changes to E/M office visit coding went into effect on January 1, 2021.  This page includes links to AMA resources as well as  specialty-specific resources  to help you as you implement these changes in your practice. 

The revisions to the E/M office visit CPT® codes (99201-99215) code descriptors and documentation standards directly address the continuing problem of administrative burden for physicians in nearly every specialty. 

With these changes, documentation for E/M office visits will now be centered around how physicians think and take care of patients and not on mandatory standards that encouraged copy/paste and checking boxes.  Key revisions include: 

• Elimination of history and physical as elements for code selection.
• Allow physicians to choose whether their documentation is based on Medical Decision Making (MDM) or Total Time. 
• Modifications to the criteria for MDM. 
• Deletion of CPT code 99201. 
• Creation of a shorter prolonged services code. 

AMA Resources 

• CPT® (Current Procedural Terminology)  
• CPT® Evaluation and Management : A historical overview and summary of the E/M coding revision for office visits.

​ Educational Modules 

• Table  illustrating the MDM revisions.
• 10-step checklist  to prepare your practice for E/M office visit changes.
• Detailed  PDF  with the E/M code and guideline changes. 
• Commercial health plans and E/M codes:  Are commercial health plans required to adopt revisions to the E/M codes?
• Dec. 3, 2020:   Will commercial payers, EHR vendors adopt revised E/M office-visit codes?
• Nov. 6, 2020:   How 2021 E/M coding changes will reshape the physician note
• Aug. 5, 2020:   E/M office-visit changes on track for 2021: What doctors must know
• Feb. 13, 2020:  How 2021 E/M guidelines could ease physicians’ documentation burdens  
• Nov. 19, 2019:  E/M prep: Avoid these pitfalls in move to new office-visit codes
• Nov. 5, 2019:   E/M prep: Your in-house practice checklist for 2021 transition  

Specialty-Specific Resources:  

• Addiction Medicine:  Resources from ASAM  
• Allergy, Asthma, & Immunology:  Resources from AAAAI  
• Regional Anesthesia and Pain Medicine:  Article from ASRA  (Dec. 7, 2020) 
• Cardiology:  Article from ACC  (Dec. 23, 2020) 
• Dermatology:  Resources from AAD  
• Emergency Medicine:  Article from ACEP  (Jan. 7, 2021) 
• Endocrinology:  Resources from Endocrine Society  
• Family Medicine:  Resources from AAFP  
• Gastroenterology:  Resources from AGA  
• Internal Medicine:  Resources from ACP  
• Neurology:  Resources from AAN  
• Neurosurgery:  Resources from CNS  
• OB/GYN:  Resources from ACOG  
• ASCO Guide to 2021 Evaluation & Management Changes  (October 2020)
• Ophthalmology:  Resources from AAO  
• Orthopaedic Surgery:  Article from AAOS  (Sep. 1, 2020) 
• Otolaryngology:  Article  (Nov. 2020) and  Resources from AAO-HNS   
• Pediatrics:  Resources from AAP
• Physical Medicine and Rehabilitation:   Resources from AAPM&R  
• Psychiatry:   Resources from APA  
• Rheumatology:   Article from ACR  (Dec. 8, 2020) 
• Surgery:   Resources from ACS  
• Urology:   Resources from AUA  

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Office/Outpatient E/M Visit Coding Changes

New guidelines, new codes.

Physicians and other practitioners who are paid under the Medicare Physician Fee Schedule (MPFS) bill for common office or other outpatient visits for evaluation and management (E/M) services using a set of Current Procedural Terminology (CPT)* codes that distinguish visits based on the level of complexity, site of service, and whether the patient is new (CPT codes 99201-99205) or established (CPT codes 99211-99215).

For the first time since it was introduced in 1992, the office/outpatient E/M CPT code set has been extensively revised, including the addition of a new code to report incremental time associated with prolonged office or other outpatient services.

Effective January 1, 2021, new reporting guidelines were implemented and code selection for office/outpatient E/M services is based on:

Office/Outpatient E/M Codes

See the table that highlights the changes to the office/outpatient E/M code descriptors.

Reporting Guidelines

Look at the major differences in reporting guidelines for office/outpatient E/M visits.

History and Physical Examination

See how to document H&P for office/outpatient E/M services.

Take a look at the changes in time reporting requirements for office/outpatient E/M codes.

Medical Decision Making

See both the levels and elements of medical decision making.

Regulatory History and Advocacy

Take a look at the timeline and Medicare Physician Fee Schedule rulemaking process.

Frequently Asked Questions

You may have many questions about MDM, time and how to determine the level of an office/outpatient E/M visit. Find your answers here.

Our webinars show how surgeons should use office/outpatient E/M coding guidelines to properly report such services and avoid claims denials.

Contact ACS Advocacy

If you have questions about ACS Advocacy,

please contact The ACS Advocacy team.

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• / August 2020
• / New E/M Rules for Office Visits, Part 1: The Medically Relevant Patient History

New E/M Rules for Office Visits, Part 1: The Medically Relevant Patient History

• Mark Complete

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If you have been using the office-based evaluation and management (E/M) codes, you’ll know that the history component involves an oner­ous series of steps—but not for much longer!

Almost gone are the days of obtain­ing and documenting a review of 10 or more body systems plus a past medical history, family history, and social history plus a chief complaint plus a minimum of four elements to the history of the present illness.

Big changes coming. Beginning Jan. 1, 2021, Medicare is streamlining the requirements for patient history when using office-based E/M codes 99202-99215. The history will need to be medically appropriate, which means that you need to document only infor­mation that will be medically relevant for the physician. What’s relevant? This will vary depending on the nature of the patient encounter.

This month and next month, Savvy Coder provides some typical examples seen daily in ophthalmic practices.

Get ready with technician training. While this change to the documentation requirements is great news, technicians will need some help. In addition to giving them the AAOE’s new resources (see “ Train Your Staff ”), ophthalmologists should walk their technicians through the types of information that are need­ed for a medically relevant history.

Who can obtain and document the history? Any part of the chief com­plaint or history that is recorded in the medical record by ancillary staff or the beneficiary (patient) does not need to be documented again by the billing practitioner. Instead, that person may review the information, update or sup­plement it as needed, and indicate in the record that he or she has done so.

Cataract Example

When patients are referred for cata­ract surgery, John T. McCallister, MD, asks that his technicians capture these details of their blurred vision.

• Laterality: Is the blurriness in the right eye, left eye, or both?
• Onset: Gradual or sudden?
• Duration: When did the blurred vision start?
• Effect on daily life: What activities are affected? Specifically ask about driv­ing, working, reading, using a computer or device, watching television, and doing crafts or other activities.
• Glare or halos: Is the patient both­ered by glare or halos? If so, during daytime and/or nighttime? In the rain? In certain indoor lighting conditions?
• Surgical history: Any history of refractive surgery? If so, what type of refractive surgery, when, how many times, and can we get past records?
• Injury: Any history of trauma or other injury?
• Eye disorders: Any concurrent eye disorders (e.g., blepharitis, diabetic retinopathy, dry eye syndrome, epiret­inal membrane, epithelial basement membrane dystrophy, glaucoma, lattice degeneration, macular dystrophy, pseu­doexfoliation syndrome, retinal tear or detachment, uveitis, etc.)?
• Medications: Taking, or have pre­viously taken, any prostate or bladder medications? Any blood thinners?
• Family history: Any family members with eye issues?
• Allergies: Any medication allergies? Latex allergies?
• Anesthesia: Any adverse reactions to anesthesia?
• Noncovered services: What has the patient heard regarding premium IOLs and femtosecond lasers?

Dr. McCallister is a comprehensive ophthalmologist at Northern Virginia Ophthalmology Associates, which has offices near Alexandria and D.C.

Cornea Example

There are many potential indications for a corneal transplant, such as scar­ring, endothelial failure, dystrophy, infection, and trauma. That said, David B. Glasser, MD, considers the following as medically relevant: 

• Chief complaint: What is the prima­ry problem for which you seek consul­tation and possible surgery? What are the vision problems? Describe any pain or discomfort.
• Laterality: Right eye, left eye, or both? If both, which is worse?
• Duration: When did it start/how long has it been going on?
• Cause: Do you think anything in particular caused it?
• Onset: Did it come on suddenly or gradually?
• Stability: Is it getting better or worse or has it been stable? If stable, for how long has it been stable?
• Associations: Does anything in particular make the symptoms better or worse?
• Effect on daily life: What activities does it affect? Driving, reading, any specifics?
• Surgical history: Any past eye sur­gery? What was the surgery and when did it take place?
• Medications: Any systemic or topical medications?

Dr. Glasser is the Academy Secretary for Federal Affairs.

Glaucoma Example

Under the new rules, Emily P. Jones, MD, will be asking her technicians to document the following elements for a typical glaucoma patient:

• Surgical history: Any history of prior eye surgeries?
• Family history: Is there a strong family history of glaucoma with glau­coma surgeries or vision loss at an early age?
• Medical history: Examples of perti­nent histories include:
• A stroke resulting in homony­mous visual field defects.
• A history of poorly controlled diabetes with renal disease, limb amputations, hospitalizations.
• A distant history of trauma to one eye.
• Medications: Examples of pertinent details include:
• Any glaucoma medications that a patient took in the past but did not tolerate or did not respond to?
• A history of asthma with use of inhalers that would make the patient a poor candidate for beta-blocker drops?
• Long-term use of oral or inhaled steroids?
• A history of exudative macular degeneration with intravitreal Avastin injections (which can lead to very elevated eye pressure).

Dr. Jones is a glaucoma specialist at the Devers Eye Center in Portland, Oregon.

Pediatric Example

Suppose a patient is referred by his pediatrician to your practice for stra­bismus?

Robert S. Gold, MD, FAAP, would want to make sure that the following information is documented in the patient’s record:

• Direction of misalignment: In, out, up, or down?
• Duration: Days, months, or years?
• Constant or intermittent strabismus?
• Double vision?
• Is it better or worse at certain times of day?
• Family history of strabismus/ambly­opia?
• Eye history: Used glasses, patching, and/or undergone surgery?
• Pertinent information from past history, medical history, neurologic his­tory, and genetic history (syndromes).

And what if you’re examining an adult strabismus patient? In that case, Dr. Gold would want the technician to also document any history of diabe­tes, hypertension, vascular problems, trauma, neurologic issues, and medi­cations.

Dr. Gold is a pediatric ophthalmologist at Eye Physicians of Central Flori­da, with offices in the Orlando metropol­itan area.

The Eye Visit Codes

What about the history component for Eye visit codes 92002–92014? Whether the patient is new or established, and whether the exam is limited or com­prehensive, the history documentation requirements for Eye visit codes will be the same in 2021 as they were in 2020.

Increased E/M Payments

Payments for office-based E/M codes—but not for Eye visit codes—are slated for a “significant” increase on Jan. 1, 2021. The Centers for Medicare & Medicaid Services (CMS) will an­nounce the size of those increases in November, when it publishes the 2021 Medicare Physician Fee Schedule. Un­fortunately, unless Congress intervenes to amend CMS’ budget-neutrality man­date, these increases in E/M payments could result in cuts to other codes (see this month’s Academy Notebook ).

Further Reading

New E/M Rules for Office Visits, Part 2: How to Document the Retina Exam (September 2020, EyeNet )

Taking retina histories. Plus the nonoffice exam.

New E/M Rules for Office Visits, Part 3: The Medically Relevant Exam (October 2020, EyeNet )

Anterior segment and pediatric examples.

New E/M Rules for Office Visits, Part 4: Cornea and Oculofacial Exams  (November 2020,   EyeNet )

Cornea and oculofacial examples.

All content on the Academy’s website is protected by copyright law and the  Terms of Service . This content may not be reproduced, copied, or put into any artificial intelligence program, including large language and generative AI models, without  permission from the Academy.

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Newly Released CY 2023 CPT Code Set

The American Medical Association (AMA) has recently released the Current Procedural Terminology (CPT) code set for 2023, which contains updates that aim to reduce the medical coding burden for evaluation and management (E/M) visits. In this article, out of all Evaluation and Management (E/M) guidelines, we will be focussing on revised guidelines for office visits. It includes defining, new and established patients; initial and subsequent services; and services reported separately. Let’s understand the basic classification of Evaluation and Management (E/M) services before discussing revised guidelines for office visits.

Classification of Evaluation and Management (E/M) Services

The E/M section is divided into broad categories, such as office visits, hospital inpatient or observation care visits, and consultations. Most of the categories are further divided into two or more subcategories of E/M services. For example, there are two subcategories of office visits (new patient and established patient) and there are two subcategories of hospital inpatient and observation care visits (initial and subsequent). The subcategories of E/M services are further classified into levels of E/M services that are identified by specific codes.

The basic format of codes with levels of E/M services based on medical decision-making (MDM) or time is the same. First, a unique code number is listed. Second, the place and/or type of service is specified (e.g., office or other outpatient visits). Third, the content of the service is defined. Fourth, time is specified. The place of service and service type is defined by the location where the face-to-face encounter with the patient and/or family/caregiver occurs. For example, service provided to a nursing facility resident brought to the office is reported with an office or other outpatient code.

New and Established Patients

Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by physicians and other qualified healthcare professionals who may report evaluation and management services.

New Patient: A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Established Patient: An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

In the instance where a physician or other qualified health care professional is on call for or covering for another physician or other qualified health care professional, the patient’s encounter will be classified as it would have been by the physician or other qualified health care professional who is not available. When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician. Note that, no distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.

Initial and Subsequent Services

Some categories apply to both new and established patients (e.g., hospital inpatient or observation care). These categories differentiate services by whether the service is the initial service or a subsequent service. For the purpose of distinguishing between initial or subsequent visits, professional services are those face-to-face services rendered by physicians and other qualified healthcare professionals who may report evaluation and management services.

Initial Service: An initial service is when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stays.

Subsequent Service: A subsequent service is when the patient has received professional service(s) from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the admission and stays.

In the instance when a physician or other qualified health care professional is on call for or covering for another physician or other qualified health care professional, the patient’s encounter will be classified as it would have been by the physician or other qualified health care professional who is not available. When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and subspecialty as the physician. For reporting hospital inpatient or observation care services, a stay that includes a transition from observation to inpatient is a single stay. For reporting nursing facility services, a stay that includes transition(s) between skilled nursing facility and nursing facility level of care is the same stay.

Services Reported Separately

The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.

The performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The interpretation of the results of diagnostic tests/studies (i.e., professional component) with the preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended.

The physician or other qualified health care professional may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant separately identifiable E/M service. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.

To discuss revised guidelines for office visits, we referred to ‘ 2023 CPT E/M descriptors and guidelines published by American Medical Association (AMA). Note that these guidelines are to be used by the reporting physician or other qualified healthcare professional to select the appropriate level of service. These guidelines do not establish documentation requirements or standards of care. The main purpose of documentation is to support the care of the patient by current and future healthcare team(s). These guidelines are for services that require a face-to-face encounter with the patient and/or family/caregiver.

We hope this article has given you a good understanding of revised guidelines for office visits, you can visit the AMA reference link for a detailed understanding. If you are busy in patient care and can’t keep track of E/M coding updates, we can assist you. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services .

We take complete ownership of billing services and ensure accurate payment collection for delivered services. To know more about our medical billing and coding services, email us at: [email protected] or call us at: 888-357-3226 .

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• Physician Fee Schedule (PFS) Payment for Office/Outpatient Evaluation and Management (E/M) Visits – Fact Sheet (PDF) - Updated 01/14/2021
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