Level 2 Visits 107 Level 2 Visits Level 2 Visits This article provides information and examples of the changes that will be implemented for office and other outpatient evaluation and manage- ment (E/M) codes on January 1, 2020. In this article, we’ll look at example scenarios that might be reported with codes at each level of office E/M service. As noted in previous articles, code 99201 will be deleted on January 1, 2021. Because code 99211 (see “2020 Versus 2021: When Is 99211 Reported?”) is a service provided by clinical staff under the in-office supervision of a physician or QHP, no physician time or MDM is required for this level of service. For these reasons, our focus on code level selection begins with level 2. Level 2 Codes Codes indicate whether a patient is new or established for each level of service. ★▲99202 Office or other outpatient visit for the evaluation and manage- ment of a new patient, which requires a medically appropriate history and/or examination and straightforward medical deci- sion making. When using time for code selection, 15–29 minutes of total time is spent on the date of the encounter. ★▲99212 Office or other outpatient visit for the evaluation and manage- ment of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10–19 minutes of total time is spent on the date of the encounter. Code Selection Straightforward MDM is required when selecting the level 2 code based on MDM, regardless of whether the patient is new or established. However, codes for new patient visits have higher time requirements. Table 1 lists the elements that may support straightforward MDM. Two of 3 elements must be met to support a level of MDM. Examples of the number and complexity of problems addressed and risk of complica- tions and/or morbidity or mortality of patient management are only examples. Actual patient presentations may increase or decrease the complexity of MDM. Ped Office-based EM Coding booklet interior.indd 107 Ped Office-based EM Coding booklet interior.indd 107 9/14/20 12:02 PM 9/14/20 12:02 PM
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