The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) are implementing changes to the office and outpatient E&M code guidelines effective January 1, 2021. This is the first major overhaul in more than 25 years, with the potential to give providers more time to spend with patients and reduce administrative burden.
A few key points in regards to the changes are:
CPT Code 99201 - (New patient low complexity) has been deleted
CPT Code 99417 - (Prolonged services) has been added
For 2021 guidelines, code selection does not depend on the amount of history or exam elements documented. The level of service will be determined by either Medical Decision Making or Time. A medical appropriate history and exam is still required.
Time includes both face-to-face and non-face-to-face time spent by the provider and is calculated based on the services provided to the patient on the date of encounter only and only the provider time.
For Services 75 minutes or longer, providers will use CPT Code 99205 for a new patient and CPT Code 99215 for an established patient as well as CPT Code 99417 in increments of 15 minutes.
For those providers using NextGen the new version of E&M calculation will be available January 1st. For those providers not using NextGen please be sure your EHR and billing team will be prepared for these new guidelines.
In this Quick Reference Guide, we will explain how to submit E&M codes using the Finalize template. This Guide assumes, that providers have a basic understanding as to how to access and navigate the Finalize template.
Submitting the E&M Code
In order to Submit E&M codes from the Finalize template. You must have at least one diagnosis. The added diagnoses can be found under the Today's Assessment panel. (See image below)
Additional diagnoses can be added, by clicking Add.
Evaluation and Management Coding
Effective January 01,2021 the E&M code may be selected based strictly on MDM (Medical Decision Making) or Time.
Medical Decision Making
From the Evaluation and Management Coding panel:
- Select one of the Medical Decision Making levels of complexity,
- Click Submit Code.
When selecting Medical Decision Making, the E&M Code will auto populate in the Visit code and Calculated E&M code fields. (See image below)
Calculating by Time
Aside from calculating codes by Medical Decision Making. Providers have the option to calculate their code by entering the time that they personally spent on patient care for the current encounter. To Calculate & Submit Codes based on time:
- Click the Time field to enter time in minutes.
- Click Submit Code
After entering Time, the E&M Code will auto populate in the Visit code and Calculated E&M code fields. (See image below)
Also, effective 1/1/2021 there is a new HCPCS add-on code G2211 for visit complexity. This code may be used by primary care and certain other specialties who are addressing health needs with a consistency and continuity over a long period of time. This code may be used for new and established patients. The code can only accompany the traditional E&M codes, 99202-99215. (See image below)
