Evaluation and Management Codes: A Work in Progress 97 Evaluation and Management Codes: A Work in Progress Evaluation and Management Codes: A Work in Progress Margie C. Andreae, MD, FAAP, shared important information and updates related to changes to office and other outpatient evaluation and management (E/M) codes 99202–99205 and 99211–99215 during the American Academy of Pediatrics (AAP) coding webinar, “2021 Evaluation and Management (E/M) Office Visit Changes: Stay in the Know!” Dr Andreae shared the following key points during her webinar: Codes Affected Only codes 99202–99205 and 99211–99215 are changed in 2021. Current guidelines (CPT and 1995 and 1997 Medicare documentation guidelines) apply to all other codes. 2021 Code Selection Code selection is based on medical decision-making (MDM) alone or time alone. There is no requirement that more than 50% of time is spent in counseling and/or ­ coordination of care. The same MDM requirements support a level of service for both new and established patients (ie, MDM requirements are the same for 99204 and 99214). Expanded definitions included in CPT 2021 (eg, defined types of problems and data) are intended to decrease the need for audits. History and Examination Extent of history and examination performed and documented is deter- mined by the reporting clinician (ie, medically appropriate in the clinician’s judgment) and not used in code selection. Physicians and other qualified health care professionals (QHPs) should document history and examina- tion to support ongoing patient care and for medicolegal purposes. Documentation Documentation of time spent by a physician or other QHP does not require documentation of each increment of time but rather the total time spent on the date of the encounter. Ped Office-based EM Coding booklet interior.indd 97 Ped Office-based EM Coding booklet interior.indd 97 9/14/20 12:02 PM 9/14/20 12:02 PM
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