CPT Evaluation and Management (E\M)

CPT® Evaluation and Management (E/M)
Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes

This document includes the following CPT E/M changes,
effective January 1, 2021:

• E/M Introductory Guidelines related to Office or Other Outpatient Codes 99202-99215
• Revised Office or Other Outpatient E/M codes 99202-99215

For the complete version of E/M Introductory guideline changes, Office or Other Outpatient (99202-99215) code changes, Prolonged Services code (99354, 99355, 99356, 99XXX) and guideline changes, see Complete E-M Guideline and Code Changes.doc.
Note: this content will not be included in the CPT 2020 code set release

Category I

Evaluation and Management (E/M) Services Guidelines
Guidelines Common to All E/M Services

Time

The inclusion of time in the definitions of levels of E/M services has been implicit in prior editions of the CPT codebook. The inclusion of time as an explicit factor beginning in CPT 1992 is done to assist in selecting the most appropriate level of E/M services. Beginning with CPT 2021 and except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes (99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215). Different categories of services use time differently. It is important to review the instructions for each category.

Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time. Therefore, it is often difficult to provide accurate estimates of the time spent face-to-face with the patient.

Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service. Time may only be used for selecting the level of the other E/M services when counseling and/or coordination of care dominates the service.

When time is used to select the appropriate level for E/M services codes, time is defined by the service descriptors. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health care professional. For office or other outpatient services, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211.

A shared or split visit is defined as a visit in which a physician and other qualified healthcare professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of a service for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and or other qualified health care professional(s) assessing and managing the patient on the date of the encounter is summed to define total time. Only distinct time should be summed for shared or split visits (ie, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).
When prolonged time occurs, the appropriate add-on code may be reported. The appropriate time should be documented in the medical record when it is used as the basis for code selection.

• 
  ▪ Total time on the date of the encounter (office or other outpatient services [99202-99205, 99212-99215]): For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).

Physician/other qualified health care professional time includes the following activities, when performed

• ▪ preparing to see the patient (eg, review of tests)
  ▪ obtaining and/or reviewing separately obtained history
  ▪ performing a medically appropriate examination and/or evaluation
  ▪ counseling and educating the patient/family/caregiver
  ▪ ordering medications, tests, or procedures
  ▪ referring and communicating with other health care professionals (when not separately reported)
  ▪ documenting clinical information in the electronic or other health record
  ▪ independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  ▪ care coordination (not separately reported)

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