Documentation for E/M Office Visits in 2021
Documentation for E/M Office Visits in 2021
March 6, 2021 Jackson Madison County General Hospital
Presented by Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
Acevedo Consulting Incorporated
Disclaimer
? The final 2021 Medicare physician fee schedule rule (CMS 1734-F) was published on 12/1/20. The COVID relief act put the add-on code, G2211, on hold. We have made every reasonable attempt to represent the new policies for E/M Office/Other Outpatient Visits in this presentation.
? Definitions and examples of 2021 E/M CPT codes do not include the entirety of the codes' definitions or guidelines. Code selection should be made based on the complete E/M definitions and guidelines, and the supporting clinical documentation.
? This presentation reviews the changes to Office/Other Outpatient E&M codes only. The requirements for other E/M codes can be found in the CPT book and CMS's 1995 and 1997 Documentation Requirements.
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Agenda
? Coding Office Visits based on Time
? "Add on" codes
? Coding Office Visits based on MDM ? Final Comments
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Biggest E/M CPT? Changes in 2021
? Only office or other outpatient visits are impacted
? 99202- 99205
? Not a typo ? 99201 is deleted
? 99212-99215
? 99211 remains and is not impacted by these changes
? Consultations, Hospital, SNF/NF, Home, ALF Visits are not included in these code changes
? 3 Key Components will continue to determine code selection
? Level of service is now chosen based on time or medical decision making
? How time is computed changes dramatically ? Determining medical decision making is more definitive ? Medically appropriate history and/or physical exam
? No more counting bullets!
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2021: What is and isn't changing
? All medical necessity requirements remain in place whether choosing 99202-99215 based on time or medical decision making.
? The documented Chief Complaint/Reason for Today's Visit and the narrative History of Present Illness (HPI) will set the stage for determining the complexity of MDM.
? Rules for modifiers (e.g., -25) have not changed ? Previously nebulous terms such as "stable chronic illness," or when a
"problem" can be counted in determining MDM are now defined.
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