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Don’t Lose $64 Per CPT 99201 – 99215 Office Visits for New and Established Patients

Determining whether a patient is new or established shouldn’t be complicated — but coding CPT 99201-99215 office visits is oftentimes not so clear. Miscoding these E/M visits, however, can cost you thousands of dollars each year in lost revenue.

In fact, selecting an established patient when you should have billed a new patient office visit can cost you $64 per visit. But help is at hand. Check your skills with the following foundations and quiz on commonly miscoded scenarios.

Adhere to CPT 99201 – 99205 vs 99211 – 99215 Office Visit Requirements

So what’s the difference between a new or established patient? According to CPT® guidelines:

• A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.
• An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Whether you’re coding for a new or an established patient, there are three core parts, or criteria, to the code. Within each part, there are varying degrees of complexity which you will assign to your patient. These include:

• History and Examination – Problem focused, expanded problem focused, detailed, or comprehensive
• Medical Decision Making (MDM) – Straightforward, low, moderate, or high
• Presenting Problem (Severity) – Minimal, self-limited or minor, low to moderate, or moderate to high

Physicians should follow E/M documentation for use of CPT 99201-99215 office visit codes, based on visit complexity and whether patient is a new or established patient. For a new patient, you have to meet all 3 criteria, but for an established patient you only need two.

New Patient CPT Codes 99201 – 99205:

• 99201 – Problem focused, straightforward MDM, minimal severity, average 10 minute face-to-face visit
• 99202 – Expanded problem focused, straightforward MDM, self-limited or minor severity, average 20 minute face-to-face visit
• 99203 – Detailed, low MDM, low to moderate severity, average 30 minute face-to-face visit
• 99204 – Comprehensive, moderate MDM, moderate to high severity, average 45 minute face-to-face visit
• 99205 – Comprehensive, high MDM, moderate to high severity, average 60 minute face-to-face visit

Established Patient CPT codes 99211 – 99215:

• 99211 – Minimal severity, average 5 minute face-to-face visit
• 99212 – Problem focused, straightforward MDM, self-limited or minor severity, average 10 minute face-to-face visit
• 99213 – Expanded problem focused, low MDM, low to moderate severity, average 15 minute face-to-face visit
• 99214 – Detailed, moderate MDM, moderate to high severity, average 25 minute face-to-face visit
• 99215 – Comprehensive, high MDM, moderate to high severity, average 40 minute face-to-face visit

Note: Face-to-face time refers solely to the time spent with the physician, not other support staff.

Test Your Skills With 3 CPT 99201 – 99215 Office Visits Tricky Scenarios

Even knowing the codes and levels of severity, deciding when to bill for a new or established patient visit is tricky because of the different variables. Use these 3 scenarios to quiz yourself and spot clues to help you recall and properly code your patient CPT 99201-992015 office visits:

Scenario #1: A patient receives a facial in the ENT medical spa and then makes an appointment to see the ENT. Is the ENT visit billed as a new or established patient visit?

Answer: New, because for the visit to be classified as an established patient, the code must be billed using a CPT code.

Scenario #2: A pediatrician sees a patient, suspects ADHD, and refers the patient to a developmental pediatric specialist within the same practice with the same Tax ID number. Is the patient’s visit with the developmental pediatric specialist billed as a new or established patient encounter?

Answer: New, provided the specialist is recognized as a unique specialty and patients are referred for specialty areas that specialist handles.

Caveat: There are many specialties that can practice under the same Tax ID and be counted as different specialties, so you have to check how you are filed. For example, a patient who gets an in office referral to an ophthalmologist from an Optometrist might be considered an established patient.

Scenario #3: A physician provided an E/M service for a patient who was seen a year ago in the same office by a physician of the same specialty but different subspecialty. Will the health insurance company reimburse a New Patient E/M code if reported in this situation?

Answer: No, not if they are following CMS policy. Under CMS policy, they will reimburse a New Patient E/M code if the patient has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years. In this case the patient was seen only one year ago. Prepare for Massive 2021 CPT 99201-99215 Changes While you don’t have to worry about any E/M changes in 2020, effective January 1, 2021, CMS is implementing a few significant E/M code changes for CPT 99201-99215 office visit codes, including:

• 99201 will be deleted
• More flexibility to document new or established visits based on the current method, time, or medical decision making
• New term clarifications and definitions for MDM
• Changes in how time is calculated, including a new time range for visits and non-face-to-face time spent that same day

It’s important to know the distinction between new and established patients now and get it right before CPT E/M 2021 changes take place. You need strategies to help, such as tips on how to utilize the CPT decision tree to accurately determine a new vs established patient, and how to ensure your records are audit-proof to justify new and higher-level visits.

For all this and more, including how to cut down on your E/M denials and receive higher reimbursements for your office visits, sign up for national coding expert,  Kim Garner Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO’s 60-minute online workshop today!

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Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

All specific references to CPT codes and descriptions are © 2023 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Download the Office E/M Coding Changes Guide (PDF)

List With Office Visit CPT Codes (New & Established Patients)

The CPT codes for office visits can be found in the CPT manual; under range CPT 99202 until 99205 for office visits of new patients . For office visits of established patients, you can use range 99211 to CPT code 99215. We also included CPT 99070 in case you need to bill extra supplies/materials for office visits and CPT code 99072 if extra staff and supplies were needed during a Public Health Emergency.

CPT Code 99070

Long description of CPT 99070 : Supplies and materials [except spectacles] provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided].

Short description: Extra supplies/materials for office visit.

CPT Code 99072

Long description of CPT 99072 : Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service[s], when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.

Short description: Extra supplies and staff time for office visits during Public Health Emergency.

CPT Code 99202

Long description of CPT 99202 : Office or other outpatient visit for the evaluation and management of a new patient , which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.

Short description: 15-29 minute office visit for new patient evaluation and management.

CPT Code 99203

Long description of CPT 99203 : Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.

Short description: 30-44 minute office visit for new patient evaluation and management.

CPT Code 99204

Long description of CPT 99204 : Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spend on the date of the encounter.

Short description: 45-59 minute office visit for new patient evaluation and management.

CPT Code 99205

Long description of CPT 99205 : Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code+ selection, 60-74 minutes of total time is spent on the date of the encounter.

Short description: 60-74 minute office visit for new patient evaluation and management.

CPT Code 99211

Long description of CPT 99211 : Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional

Short description: Short office visit for established patient management.

CPT Code 99212

Long description of CPT Code 99212 : Office or other outpatient visit for the evaluation and management 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 spent on the date of the encounter.

Short description: 10-19 minute office visit for established patient management.

CPT Code 99213

Long description of CPT 99213 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.

Short description: 20-29 minute office visit for established patient management.

CPT Code 99214

Long description of CPT 99214 : Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using time for code selection, 30-39 minutes of total time is spend on the date of the encounter.

Short description: 30-39 minutes office visit for established patient management.

CPT Code 99215

Long description of CPT 99215 : Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

Short description: 40-54 minutes office visit for established patient management .

https://www.aapc.com/codes/cpt-codes-range/99211-99215/

https://www.aapc.com/codes/cpt-codes-range/99202-99205/

https://www.aapc.com/codes/cpt-codes/99070

https://www.aapc.com/codes/cpt-codes/99072

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• v.14(7); 2022 Jul

Outpatient Visit Current Procedural Terminology Code Level Selection Trends in Hand Surgery Following Criteria Changes by the American Medical Association

Jack g graham.

1 Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA

Kyle Plusch

Michael rivlin, samir sodha.

2 Department of Orthopaedic Surgery, Hackensack University Medical Center, New York, USA

Greg G Gallant

Pedro beredjiklian.

Introduction: Beginning on January 1, 2021, the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) implemented considerable revisions with regard to the outpatient evaluation and management (E/M) criteria dictating the Current Procedural Terminology (CPT) code level selection. The primary goal of the current study was to determine how the recent E/M coding criteria changes have impacted code level selection by orthopedic hand surgeons in the outpatient setting.

Materials and methods: All outpatient visits within the hand and wrist surgery division of a single orthopedic practice were collected during two timeframes: March 1, 2019, to June 30, 2019, and March 1, 2021, to June 30, 2021. Procedure codes and insurance categories were collected for each visit. The primary endpoint analyzed was the visit level of care based on CPT E/M codes. For each timeframe, we determined the number of total visits that were coded at each level and expressed them as a percentage of the total visits for that time period. The insurance plan billed for each visit was recorded and classified as Medicare, Medicaid, Workers' Compensation, or commercial.

Results: In 2019, prior to the billing level requirement changes, 7.2% of all visits were billed as level 2, 84.8% of all visits were billed as level 3, and 7.8% of all visits were billed as level 4. In 2021, 1.9% of visits were billed as level 2, 47.3% of visits were billed as level 3, and 50.5% of visits were billed as level 4. Level 1 and 5 visits did not exceed 0.5% in either timeframe. Within each insurance category, the proportion of visit levels of care followed a similar trend of reduced level 2 and 3 visits and increased level 4 visits from 2019 to 2021.

Conclusion: We noted a significant trend toward higher code level selection following the recent code level changes, and we anticipate these recent code selection trends to have major financial implications moving forward.

Introduction

On January 1, 2021, the Centers for Medicare and Medicaid Services (CMS) implemented considerable revisions to the outpatient evaluation and management (E/M) criteria dictating Current Procedural Terminology (CPT) code level selection [ 1 , 2 ]. It has been well-documented that physicians spend a disproportionate amount of time working on the electronic health record (EHR), often at the expense of face-to-face time with the patient [ 3 , 4 ]. As a part of their “Patients over Paperwork” initiative, the CMS sought to help diminish administrative burden and simplify the documentation required of physicians to justify code level selection in the outpatient setting [ 1 , 5 , 6 ]. These revisions represented the first major overhaul in E/M coding in over two decades.

These recent changes place the onus of the coding level on the complexity of medical decision-making (MDM) and not on the documentation requirements on the history and physical examination sections of the medical record as had been the case under the previous system [ 2 ]. Physicians now have the flexibility to document the pertinent history and physical examination findings in the EHR “as medically appropriate” to support their MDM. While the CPT codes have remained the same, the level of service (LOS) is now determined by MDM or total time spent by the physician on the date of the encounter. Time spent includes reviewing pertinent data or notes, face-to-face interaction, and time spent documenting or placing orders in the EHR on the day of the encounter only. MDM takes into account the number and complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and/or morbidity/mortality associated with the management of the patient’s conditions [ 1 ]. Under the previous system, the extensive documentation required to reach a higher LOS may have deterred subspecialists from higher-level code selection. These changes are particularly impactful in fields such as hand surgery, where the appropriate history and physical examination can often be especially focused.

The purpose of the current study was to determine how the recent E/M coding criteria changes have impacted code level selection by orthopedic hand surgeons in the outpatient setting. We hypothesized that the new emphasis on MDM would be associated with higher-level CPT code selection by hand surgeons. Given that visit complexity is directly tied to reimbursement, the secondary outcome measured was the number of corresponding relative value units (RVUs) per visit in this same set of patients under the new coding criteria.

Materials and methods

Following Institutional Review Board approval, including a waiver of informed consent per institutional protocol, we performed a billing database search to identify all in-person outpatient visits among 18 fellowship-trained hand surgeons within a single orthopedic practice during two timeframes: March 1, 2019, to June 30, 2019, and March 1, 2021, to June 30, 2021. While the billing level change occurred on January 1, 2021, the year 2020 was not included due to the significant disruption of in-person office visits associated with the coronavirus disease 2019 (COVID-19) pandemic. Patient demographics and procedure codes were collected for each visit, and internal billing records were reviewed to collect the insurance category and plan billed for each visit. Using the Physician Fee Schedule available through the CMS website, corresponding RVUs from 2019 to 2021 were also collected [ 7 ].

The primary endpoint analyzed was the visit level of care based on CPT E/M codes. Historically, many outpatient clinic visits have been billed for using one of 10 five-digit CPT codes, which represent both patient status (new versus established) and visit complexity based on LOS. All new patient visits have been represented by a CPT E/M code 9920_, with the final digit ranging from 1 (low complexity) to 5 (high complexity). Established patient visit E/M codes begin with 9921_, with the final digit also ranging from 1 (low complexity) to 5 (high complexity). The specific criteria for each E/M code selection are described in Table ​ Table1 1 below [ 1 ]. Work RVUs are assigned to each of these E/M CPT codes by the CMS as outlined in their Physician Fee Schedule [ 7 ]. Consults, post-operative visits, and fracture care follow-up (within the global period) have been unaffected by the recent changes by the American Medical Association (AMA) and CMS. Thus, we omitted these patient visits from our analysis.

Table adapted from the 2021 American Medical Association guidelines regarding CPT E/M code changes [ 1 ].

LOS = level of service; E/M = evaluation and management; CPT = Current Procedural Terminology; MDM = medical decision-making.

Starting January 1, 2021, the code 99201 was removed due to historic underutilization, meaning it is no longer possible to code a new patient visit as level 1. For each time period, we determined the number of total visits that were coded at each level and expressed them as a percentage of the total visits for that time period. The insurance plan billed for each visit was recorded and classified as Medicare, Medicaid, Workers' Compensation, or commercial. All categorical variables were compared with chi-square analysis, and continuous variables were compared with a two-sample t-test.

Over the eight months of data collection, there were 34,593 total visits among 26,935 unique patients (Table ​ (Table2). 2 ). From March 1, 2019, to June 30, 2019 period, there were 15,904 outpatient visits; the corresponding period in 2021 had 18,689 visits.

Data are presented as the number of visits (% of that year’s total visits).

LOS = level of service; E/M = evaluation and management; CPT = Current Procedural Terminology.

The proportion of visit billing levels changed substantially from 2019 to 2021. Prior to the billing level requirement changes, the majority of visits were billed as level 3 (84.8%), compared to an almost even split of level 3 and level 4 visits after changes (47.3% level 3; 50.5% level 4). The difference in the number of visits billed at levels 2, 3, and 4 between the two timeframes was significant (p < 0.001). These data are represented in Table ​ Table2, 2 , which also breaks down the levels of care for new patient visits and established patient visits separately.

Insurance data were available for 33,360 (96.4%) of the patient visits and are depicted in Table ​ Table3. 3 . Commercial insurance providers were billed for 64.9% of visits, 24.9% of visits were billed to Medicare, 9.0% of visits were billed to Workers’ Compensation, and 1.2% of visits were billed to Medicaid. Within each insurance category, the proportion of visit levels of care followed a similar trend of significantly reduced level 2 and level 3 visits and greatly increased level 4 visits from 2019 to 2021. Per the CMS Physician Fee Schedule, mean RVUs billed per visit increased significantly (p < 0.001) for all visits, new patient visits, established patient visits, and each insurance category (Table ​ (Table4) 4 ) [ 7 ].

The CPT code system dates back to 1966, one year after Congress created Medicare under the Social Security Act [ 8 ]. The AMA has overseen consistent revisions of the system ever since. In the year 2000, the CPT system was officially named the coding standard for all United States health care [ 8 ]. Today, each CPT code is five digits long and corresponds to nearly any healthcare service that can be billed for [ 5 , 8 ]. These codes are subcategorized into one of the following groups: medicine, surgery, radiology, anesthesia, E/M, pathology, and laboratory. E/M codes are the predominant subcategory utilized in the outpatient setting, including the hand surgery clinic.

Prior to recent changes by the AMA and CMS, the level of complexity for each outpatient visit was determined using a combination of three basic domains: history, physical examination, and MDM. The lowest complexity score (ranging from 1 to 5) of these three domains was used to determine the overall visit LOS. The history and physical examination sections required extensive documentation to meet higher complexity criteria. For example, all level 4 or 5 visits required the following history documentation: four or more elements of the history of present illness (HPI), 10 or more elements of the review of systems (ROS), and past medical, family, and social histories. A level 4 or 5 musculoskeletal examination required documentation of at least 30 bullet points, including specific minimums in each of the following areas: constitutional, cardiovascular, lymphatic, integumentary, musculoskeletal, and neurologic/psychiatric. These do not usually pertain to most hand surgical complaints. A level 3 visit required less ROS elements (two to nine), only a single past medical, family, or social history documented, and only 12 physical examination bullet points.

It is clear that the recent E/M documentation requirement changes made by the AMA and CMS have had a substantial impact on LOS code selection patterns in our hand and wrist surgery division. With the new emphasis on MDM and added flexibility regarding the history and physical examination documentation, our surgeons have consistently selected higher code complexities consistent with the medical complexity in a very focused, subspecialized field of surgery. Taking all patient encounter types into account, we saw a substantial increase in level 4 visits (CPT E/M code 99204 or 99214) from 7.8% in the 2019 study period to 50.5% in 2021. A corresponding decrease in level 3 visits (CPT E/M code 99203 or 99213) from 84.8% in 2019 to 47.3% in 2021 was noted (Table ​ (Table2). 2 ). These trends remained consistent, regardless of insurance type or patient status (new vs. established). Level 2 visits saw a similar decline from 7.2% of all visits in 2019 to less than 2% in 2021. Level 1 and 5 visits remained rare selections at less than 0.5% of all visits.

While CPT coding represents the “common language” for medical procedures and is essential to communication, data collection, and clinical research, this system is also closely tied to reimbursement and valuating healthcare services [ 5 , 8 , 9 ]. The Relative Value Scale Update Committee (RUC), which is made up of select physician representatives from most medical and surgical specialty societies, plays a major role in determining the value of medical services and procedures. Valuation is based on three primary components: physician work, practice expense, and professional liability insurance (PLI) [ 8 - 10 ]. Each year, the RUC is tasked with updating CPT code valuation recommendations to CMS through a strict methodology. The CMS operates under a rule of budget neutrality, meaning that the expansion in reimbursement for one procedure or service may impact the reimbursement of others [ 9 ]. CMS publishes its decisions on any proposed RVU changes and adjusts its annual conversion factor in the Physician Fee Schedule Final Rule each November [ 2 , 7 , 9 ].

As a result of the increase in LOS coding in our practice, there was a notable increase in mean RVUs per office visit in our hand surgery practice. The most substantial increase was noted in established patient visits, which saw an RVU increase of 65.2% on average (0.96 RVUs in 2019 to 1.59 RVUs in 2021). New patient visits had a mean RVU increase of 43.5% from 2019 to 2021. Insurance type did not portend any major differences in RVU increase, as all four sub-categories had significant increases in mean RVUs from 49.1% to 59.8% (Table ​ (Table4 4 ).

Tassavor et al. compared dermatology resident clinic E/M code level selection patterns between two separate two-month periods before and after the recent changes by the AMA and CMS on January 1, 2021 [ 11 ]. After analyzing over 2500 unique patient visits, they reported a similar, but smaller 13% increase in level 4 visits and a 20% decrease in level 2 visits following the recent criteria changes.

Our study has several limitations. There were unprecedented changes in our hand surgery clinic patient flow as a result of the COVID-19 pandemic, requiring a significant amount of telehealth visits [ 12 ]. For this reason, we chose to exclude the year 2020 for analysis and instead chose a four-month pre-pandemic timeframe. However, E/M coding principles prior to January 1, 2021, were mostly unchanged for two decades. While it would have been ideal to compare consecutive years, it is unlikely that our results would have differed significantly. Additionally, this study only represents an individual practice’s patient population in the northeastern United States and may or may not apply to other geographies. While the trend of increased coding complexity and RVUs was widespread across all patient visit types and insurance categories, it could be worthwhile to analyze the percentage of approved reimbursement between these groups. The present study did not investigate this. Finally, while all visit level coding was subject to our practice’s standard auditing process, it remains a possibility that billing errors were made.

Conclusions

It is unknown how uniform these recent coding patterns are among hand surgeons. Individual surgeons and practices may adapt to the regulation changes at different speeds, and LOS selection differences may become even more apparent over time. We suspect that higher complexity code selection since January 1, 2021, will become consistent across the orthopedic subspecialties; however, further investigation in this area is warranted. These findings may have been anticipated by the AMA and CMS following their simplification of documentation guidelines aimed at diminishing the administrative burden on the practicing physician. It remains to be seen what impact these trends have on future reimbursement policies and the healthcare system as a whole. What is clear, however, is that at our institution, since the E/M coding criteria overhaul beginning in 2021, there has been a significant trend toward a higher level of service code selection in hand surgery.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study. Thomas Jefferson University Institutional Review Board issued approval #22E.229. The Thomas Jefferson University Institutional Review Board has approved this research under IRB control #22E.229 (“New Evaluation and Management Code Level Selection Trends in Outpatient Orthopaedic Surgery Visits”), with a waiver of informed consent per institutional protocol.

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

What drives the level of office visit codes?

Many physicians and coders think longer documentation means charging higher level visits. Fortunately, that is not always the case. You can document less as long as you are documenting the correct and necessary information.

Medical decision making drives the level of office visit

The medical decision-making portion of evaluation and management guidelines is what ultimately determines the level billed. Higher complexity in decision making justifies higher levels.

Evaluation and Management visits have three main components:

• Physical exam
• Medical decision making.

For established patients, guidelines state that only two of these three need to be met for a given level. The Center for Medicare and Medicaid Services advises to let medical decision making drive the visit.

What does “Medical decision making should drive the visit” really mean?

This is such a grey area in the guidelines that it is causing practices to over-bill or undercharge, which will ultimately cause them to fail an audit.

CMS stated, “It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.” ( Medicare Claims Processing Manual 30.6.1)

Many practices are so confused about what this means, that they just pick the middle level and call it a day. Those practices need clarification and education on how to get to the correct level for the service performed. MEREM can help!

Below are some examples to remember when choosing the level of an office visit to the bill.

• If the provider is seeing an established patient who is coming in for a recheck,  ask yourself is the patient’s diagnosis improving or worsening?

– If the problem is improving, the level of service will likely be a level 2 (99212).

⁃ If the problem is worsening, the level of service is likely a level 3 (99213).

• For established patients coming in with a new problem , these level of service is likely a level 3 (99213) or level 4 (99214). The final level for this patient will depend on the diagnosis and treatment performed during the service.
• Code 99215 is used to report High MDM. 99215 is reserved for those patients who require extensive workup regarding Chronic Illnesses with severe exasperations or acute illness or injuries that threaten loss of life or bodily function. Management options for these patients may include IV drug therapy, Emergency Surgery or a DNR status because of poor prognosis.

Let MEREM Health help you conquer the challenges of coding your office visits. Call us to get a free quote at 205-329-7519.

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The biggest changes in evaluation and management coding since 1997 will take effect Jan. 1, 2021. It is time to prepare for them now.

KEITH W. MILLETTE, MD, FAAFP, RPH

Fam Pract Manag. 2020;27(5):29-36

Author disclosure: no relevant financial affiliations disclosed.

Editor's note: In its 2021 Medicare Physician Fee Schedule, CMS released new guidance regarding coding for prolonged E/M services. This article has been updated accordingly.

Say goodbye to counting exam bullet points and making sure you have correctly separated your history of present illness from your review of systems: Changes are coming that should streamline your coding and help you zip through your documentation faster.

The shift in required documentation for CPT codes 99202-99215 takes effect Jan. 1, 2021. Coding for office visits will be based solely on medical decision making (MDM) or total time, and the history and exam components will no longer be used. 1 It's the biggest change in evaluation and management (E/M) office coding since 1997.

The reforms will apply only to regular office visits (levels 2–5 for new and established patients) — not other visit types (e.g., nursing home or hospital visits) — and should help simplify many aspects of coding. They will allow family physicians to produce shorter, more readable notes that will enhance patient care and save time. They will also lead to more accurate coding and allow us to be reimbursed more fairly for the work we do.

This article outlines what you need to know about the new rules, and it includes some templates to help you prepare your mind and your EHR.

The biggest changes in evaluation and management coding in more than two decades take effect Jan. 1, 2021. They will allow physicians to code office visits based only on total time or medical decision making.

The medical decision making coding method relies on three categories: problems (the severity of the conditions for which you're seeing the patient), data (what you had to review for the visit), and risk (the patient's morbidity or mortality odds).

You can start creating coding tables and templates now, so your EHR will be optimized for faster documentation once the new rules go into effect.

OPTION 1: TOTAL TIME

Total time will be measured as the time the physician or other qualified health professional spent on that patient on the day of the encounter. It will include time spent before, during, and after the visit, including time spent documenting the visit. Yes, that means after Jan. 1, “pajama time” (the time you spend finishing your charts after your kids are asleep) can be reimbursed. But get your charts done before midnight, because time spent the following day cannot be counted.

Hospital coding can already use time spent on the patients' unit/floor before and after the visit to determine the level of service, while office coding currently counts only face-to-face time. Allowing coding by total time will correct this double standard.

On the day of the patient encounter, total time will include time spent before the visit reviewing the patient's medical record (e.g., recent visits, labs, and studies); seeing the patient in the office (face-to-face time); discussing the patient's care with other health professionals or family members; ordering medications, studies, procedures, or referrals; calling the patient or family later in the day with results and further recommendations; and documenting the visit in the medical record. Total time will not include time spent by your nurse or other clinical staff caring for the patient and will not include time you spend performing a procedure during the same office visit (the assumption is that you will bill that procedure separately, in addition to the office visit).

While it's not required under the new rules, you may want to develop a table for documentation that shows the actual minutes spent in each category of total time (before, during, and after the visit). This will provide backup verification in case of an audit that challenges coding levels.

In another welcome change, total time thresholds will be clearly spelled out under the new regimen (e.g., 30–39 minutes total time for a level 4 established patient visit). Currently, time thresholds are listed without ranges (e.g., 25 minutes face-to-face for a level 4 visit). As a result, some clinicians, coders, and insurance companies have interpreted the times listed to be minimum requirements, while others have interpreted them to be averages. The new, more specific time thresholds should decrease confusion, improve coding accuracy, and decrease insurance company denials.

An easy way to remember the new time thresholds is the “30-, 40-, 55-Minute Rule.” For established patients, total time between 30 and 39 minutes is a level 4 visit, between 40 and 54 minutes is a level 5, and prolonged services start at 55 minutes of total time, per CPT. (Note that the prolonged services code and rules differ for Medicare; see below .) Total time requirements for each visit level will remain longer for new patients than for established patients under the new rules.

Currently, when extra time is spent caring for complex or very sick patients, prolonged service codes (99354 and 99355 for office or other outpatient visits and 99356 and 99357 for inpatient visits) are often not billed because of confusion about the requirements. When they are billed, they're often incorrectly denied by insurance companies. After Jan. 1, coding for prolonged services will also be greatly simplified, leading to more of your long and complex visits being properly reimbursed. The current prolonged service codes will become a single new code that can be billed in 15-minute increments when total time exceeds a level 5 visit. (See “ Total time plus prolonged services template .”) When coding for prolonged services, make sure you don't forget to submit the level 5 code (99215 or 99205) in addition to the prolonged services code (99417).

When using total time to code visits, remember to document it at the end of the note (i.e., “My total time spent caring for the patient on the day of the encounter was XX minutes”).

OPTION 2: MEDICAL DECISION MAKING

To understand the new MDM requirements, let's look closely at the new American Medical Association (AMA) MDM chart approved by the Centers for Medicare & Medicaid Services. (See “ CPT E/M office revisions level of medical decision making .”) It shows that MDM is made up of three elements: problems, data, and risk. The level of service is based on the highest level met by at least two of the three elements, whether the patient is new or established. New patient codes are assigned higher values to recognize the work of establishing care.

Problems . These are the patient problems you are evaluating during the office visit. This element does not include other problems the patient may have that you are not addressing during the encounter, or problems managed solely by another provider.

Each visit will be designated as “minimal,” “low,” “moderate,” or “high” in this category, depending on how many problems are addressed, whether they are chronic or acute, and how stable the chronic problems are. Stable chronic illnesses could include hypertension, diabetes mellitus, or benign prostatic hyperplasia. But for coding purposes, patients with poorly controlled hypertension whose blood pressure is not at goal, or patients with diabetes whose A1C is not at goal, are considered to have chronic illnesses that are not stable.

Data . This category includes each unique test, order, or document that you had to review for the visit. Each visit will be designated as “minimal or none,” “limited,” “moderate,” or “extensive” in this category, depending on the amount of data reviewed, the complexity of the data, and where it came from.

Note a few important definitions for this category:

An “external” physician or qualified health professional is a provider from a different specialty or a totally different group practice.

An “external” note includes records, notes, and tests from external providers.

A single “unique test” for coding purposes includes panels (e.g., a basic metabolic panel is considered a single unique test).

“Independent interpretation of tests” includes looking at or interpreting a chest X-ray (CXR) or electrocardiogram (ECG) tracing (i.e., “I ordered and personally reviewed the CXR and it shows …”). You are not credited with interpretation in this category if you are also billing for your interpretation separately.

Risk . This is the patient's risk of complications, morbidity, or mortality. This category will be designated as “minimal,” “low,” “moderate,” or “high,” depending on whether the patient's problems call for discussions about things like prescription drug management, surgery, or hospitalization.

CPT E/M OFFICE REVISIONS LEVEL OF MEDICAL DECISION MAKING

Some examples.

Here are some examples of what the documentation for various levels of visits might look like under the new rules.

Level 2 office visit . This is a visit for a simple problem such as a viral upper respiratory infection or a simple recheck of a stable problem, during which you neither prescribe a new medication nor adjust an existing prescription. Or this could be a visit in which your total time is 10–19 minutes (for an established patient).

Subjective: 58 yo male returns for a recheck of R arm cellulitis. Doing well. Redness gone. No fever. Finished cephalexin yesterday .

Objective: T 98.2, R 84, BP 130/70. R arm: cellulitis is gone, no erythema, no axillary adenopathy .

Assessment/plan: Cellulitis of right upper extremity L03.113: Cellulitis is resolved. Discussed skin infections. RTC prn .

Total time spent caring for the patient on the day of the encounter was 15 minutes .

Level 3 office visit . This could be a visit in which a patient comes in with a problem and you prescribe a medication. Or it could be a visit in which your total time is 20–29 minutes.

Subjective: 43 yo female presents with a 10 d hx of frontal maxillary sinus pain, drainage, and fatigue. No fever, ST, ear pain, or cough .

Objective: T 99.2, R 16, P 72, BP 135/84. NAD. Frontal sinus tender w/ palpation, TMs nl, pharynx nl, no cervical adenopathy, CV RRR, lungs CTA .

Assessment/plan: Acute non-recurrent frontal sinusitis J01.10: Discussed sinus infections, fluids, amoxicillin 500mg TID x 7 days, RTC or call if symptoms persist or worsen .

Total time spent caring for the patient on the day of the encounter was 25 minutes .

Level 4 office visit . This could be a visit in which you address a patient's moderately complex problem, and you prescribe a medication or order and interpret/review an X-ray, an ECG, or three separate lab tests (or panels). Or this could be a visit in which your total time is 30-39 minutes.

Subjective: 68 yo male presents for recheck of DM, HTN, hyperlipidemia. He is exercising and watching his diet and weight. Vision is stable. BP is good. FBS avg 180 .

Current medications: Atorvastatin 40 mg 1 po q h, Losartan 100 mg 1 po q am, Metformin 500 mg po bid .

Objective: P 64, R 18, BP 120/70, 162 lbs. Fundii benign, PERRLA, TMs nl, throat nl, neck no adenopathy, heart S1 S2 s murmur regular, lungs clear. Extr no edema or lesions, pulses intact, can feel 3/3 touches w LEEP filament .

A1C 4/20 7.1, 8/20 8.2, Creatinine 8/20 0.9, LDL chole 8/20 55 .

Assessment/plan:

Dyslipidemia E78.5: LDL within goal, continue atorvastatin .

Essential hypertension I10: BP is well controlled, continue losartan .

Type II diabetes without complication, without long-term use of insulin E11.9: A1C not to goal, metformin increased to 1000 mg bid. RTC 4 months with fasting lab .

Total time spent caring for the patient on the day of the encounter was 35 minutes .

Level 5 visit . This could be a visit in which you see a very acutely sick patient who requires admission to the hospital (assuming you are not admitting the patient yourself, because then you would bill for the admission only). Another example of a level 5 office visit is caring for a very sick patient with high-complexity problems, for which you order and interpret an X-ray or ECG, plus order and review three lab tests or panels. Or this could be a visit in which your total time is 40–54 minutes.

Example (using total time):

Subjective: 22 yo male presents with a 2 wk hx of depressed mood, crying spells, poor appetite assoc w/ 10 lb wt loss, problems getting and staying asleep, poor concentration, anxiety, and loss of pleasure (no longer fishing). He denies irritability or suicidal ideation. Nonsmoker, nondrinker. No access to guns. Denies prior hx of depression or fm hx of depression/mental illness. Job is going well, no financial concerns, no family concerns, and no addiction concerns. Symptoms started after his girlfriend broke up with him .

Objective: P 92, R 18, BP 138/88, 195 lbs. Alert, cooperative, good eye contact but appears slightly tearful/sad. Normal reasoning. Good insight .

Current medications: none

Assessment/plan: Current moderate episode of major depressive without prior episode F32.1. Discussed depression at length (depression handout given and discussed). Start to walk/exercise. Download and use recommended depression phone apps. Begin sertraline 50 mg 1 po q am. Risks and benefits of medication discussed. Recheck 2 wks. Call, email, text, or RTC sooner if symptoms should worsen or suicidal ideation should develop .

Total time spent caring for the patient on the day of the encounter was 45 minutes .

TEMPLATES AND FURTHER SIMPLIFICATIONS

Is it possible to make the new coding changes even more doctor-friendly and still come up with the correct code most of the time? I believe so. I looked closely at the new regulations and compiled three new templates.

The first is the “ Office visit tornado template ,” which combines MDM with total time in a way that allows you to quickly determine the level of the visit, and therefore the code. I call it the “tornado template,” because I hope it proves to be a concise and powerful tool to cut through the confusion of coding office visits. The template provides total time thresholds for both new and established patients, combines MDM data with risk, and adds examples of problems (diagnoses) and other helpful information.

I've also created a template for coding pre-operative visits. (See “ Coding pre-ops template .”)

As you become more familiar with the new rules, you may want to create your own documentation templates. There are other things you can do to ease your documentation burden as well. Consider combining the patient's chief complaint (CC), history of present illness (HPI), and pertinent review of systems (ROS). It should be clear in your first or second sentence what problems you are addressing at that visit (e.g., “the patient presents for a physical,” “the patient presents for evaluation of his DM, HTN, and CKD,” or “the patient presents with a new onset rash and follow-up for worsening depression”). When auditing a chart, I find it frustrating to review a long narrative that doesn't make it immediately clear what problems are being addressed at that patient encounter.

The problems addressed in the CC/HPI/pertinent ROS section should also mirror the problems in your assessment and plan.

To further shorten and improve your documentation, consider combining your assessment with your plan.

Essential hypertension I10: BP is well controlled, continue losartan ,

Dyslipidemia E78.5: LDL within goal, continue rosuvastatin ,

Type II diabetes mellitus with hyper-glycemia, E11.65: A1C not to goal, metformin increased to 1000 mg bid. RTC 3 months with fasting lab .

With the new coding changes, most of us will choose to leave out non-pertinent past medical, family, and social histories from our documentation. But I would recommend including current medications in your level 4 and 5 documentation. It is often helpful from a clinical management standpoint to know what medications the patient was on at that past visit.

In the future, perhaps the AMA will consider including more specific clinical examples for level 2 (minimal), level 3 (low), and level 4 (moderate) problems. For instance, are new-onset migraine, new-onset hypertension, pelvic inflammatory disease, sexually transmitted infections, influenza, respiratory syncytial virus bronchiolitis, and mononucleosis all considered level 4 problems? A list of several clinical examples of what constitutes minor and major surgery from a pre-op coding perspective would also be helpful.

But for now these changes provide long-awaited relief for some of our documentation frustrations. They are a game-changer, and will be a big plus for primary care.

E/M CODING REFORMS SERIES

This is the first in a series of articles about the changes to E/M coding and documentation requirements coming in 2021.

Upcoming articles:

November/December 2020 — Test your knowledge of specific coding scenarios.

January/February 2021 — Coding level 4 visits.

Editor’s Note

For more information on the coding and documentation changes, including the AAFP's new E/M reference card, visit aafp.org/emcoding .

CPT evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99XXX) code and guideline changes. American Medical Association. 2019. Accessed Aug. 12, 2020. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

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