An Overview of Evaluation and Management Changes for 2021 59 An Overview of Evaluation and Management Changes for 2021 An Overview of Evaluation and Management Changes for 2021 For services on and after January 1, 2021, Current Procedural Terminology (CPT ®) will include revised codes for office and other out­patient evaluation and management (E/M) services. Codes for these services will be distinctly different from codes for E/M services provided in other settings. This article provides a preview and an initial step in learning to use the revised codes and coding guidelines that will be implemented for services on and after January 1, 2021. Typically, for revised codes, it is beneficial to compare the current and revised code descriptors. However, revisions to codes 99202–99205 and 99212–99215 are so significant that the codes approximate new codes. Code selection will not be based on 2 or 3 of the key com­ponents of history, examination, and/or medical decision-­making (MDM). A medically appropriate history and physical examination are still elements of office and other outpatient E/M services but do not directly affect selection of a level of service. MDM alone may be used to select the level of service for an encoun- ter. The level of MDM is selected based on the ­ highest 2 of the following 3 elements: Number and complexity of problems addressed Amount and/or complexity of data to be reviewed and analyzed Risk of complications and/or morbidity or mortality of patient management The total combined face-to-face and non–face-to-face time of the reporting physician or other qualified health care professional (QHP) may be used to select the level of service in lieu of MDM. Time-based coding does not apply to code 99211 because the physician work associated with this code is in supervision of the service provided by clinical staff and not direct patient care. Time spent by clinical staff is not included in the time used in code selection for 99202–99205 or 99212–99215. Ped Office-based EM Coding booklet interior.indd 59 Ped Office-based EM Coding booklet interior.indd 59 9/14/20 12:02 PM 9/14/20 12:02 PM
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