General

New CPT® 2021 guidelines for office and other outpatient E/M services were created to reduce administrative burden on provider documentation and to align code selection with how providers practice medicine. This is the biggest change to E/M guidelines since the release of the Centers for Medicare & Medicaid Services (CMS) 1997 Documentation Guidelines for Evaluation and Management Services. E/M codes for office and outpatient services will be selected based on medical decision making (MDM) or time, effective Jan. 1, 2021.

Previously, under the 1997 E/M Rules, when billing an E/M Service for a new patient was based on three components: patient history, a physical exam, and medical decision making. And for an established patient it was based on two components: patient history or a physical exam, and medical decision making. While time may be the sole factor in selecting the level when counseling and/or coordination of care is greater than 50% of the encounter.

Now, with the new 2021 E/M Rules, when billing and E/M Service for a patient the level can be determined by either Time or MDM. The patient history and physical exam are no longer factors in determining the E/M level for encounters performed in the office. It will be the provider’s decision what levels of history and exam are required to treat the patient. In addition, the 99201 E/M Code has been deleted and is no longer to be used.

The resources found on this page are for Office Codes and Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Codes. For further information see the additional resources below.

Additional Resources

Time

Time is defined as 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).

The total time you will use for code selection includes the time spent by the provider on the date of service:

  • Preparing to see the patient;
  • Obtaining a history and performing an exam;
  • Counseling and educating the patient/family/caregiver;
  • Ordering medications, tests, or procedures;
  • Referring and communicating with other healthcare professionals;
  • Documenting in the health record;
  • Independently interpreting tests (not separately reported) and communicating results; and
  • Care coordination (not separately reported).

When using the Time to determine service level, it is recommended that a statement of the time is clearly documented in the chart note (for example, 3 minutes spent in pre-visit preparation, 14 minutes was spent with the patient, 7 minutes was spent discussing the case with the surgeon on the date of the visit, and 6 additional minutes were spent completing the note, for a total of 30 minutes).

New Patient 
Code Time (Minutes)
99202 15-29
99203 30-44
99204 45-59
99205 60-74
99XXX (add code) > 75
Established Patient
Code Time (Minutes)
99211 (minimal problem) No Time Set
99212 10-19
99213 20-29
99214 30-39
99215 40-54
99XXX (add code) > 55

Medical Decision Making (MDM)

The medical decision for office and other outpatient services is defined by three components:

  • Number and complexity of problem(s) that are assessed during the encounter
  • Amount and/or complexity of information that is reviewed
  • Risk of complications, morbidity, and/or mortality of patient management

Be aware, that the level of MDM does not apply to the 99211 code, for an office or other outpatient visit for the E/M of an established patient, that may not require the presence of a physician or other qualified health care professional (typically performed by a nurse).

Also, do note, that if a physician or other health professional reports a separate CPT code that includes interpretation and/or a report, then it should not be counted in the MDM when selecting an appropriate E/M level.

In reviewing the MDM table below, remember that only 2 of the 3 elements for that level need to be met or exceeded.

Code

 

 Level of MDM

(Based on 2 out of 3 Elements of MDM)

 

 Elements of Medical Decision Making
Number and Complexity of Problems Addressed

 

 Amount and/or Complexity of Data to be Reviewed and Analyzed

*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.

 Risk of Complications and/or Morbidity or Mortality of Patient Management
99211 N/A N/A N/A N/A
99202

99212

 Straightforward Minimal

  • 1 self-limited or minor problem
 Minimal or none Minimal risk of morbidity from additional diagnostic testing or treatment
99203

99213

 Low Low

  • 2 or more self-limited or minor problems;

or

  • 1 stable chronic illness;

or

  • 1 acute, uncomplicated illness or injury
 Limited

(Must meet the requirements of at least 1 of the 2 categories)

Category 1: Tests and documents

  • Any combination of 2 from the following:
    • Review of prior external note(s) from each unique source*;
    • review of the result(s) of each unique test*;
    • ordering of each unique test*

or

Category 2: Assessment requiring an independent historian(s)

(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)

 Low risk of morbidity from additional diagnostic testing or treatment
99204

99214

 Moderate Moderate

  • 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;

or

  • 2 or more stable chronic illnesses;

or

  • 1 undiagnosed new problem with uncertain prognosis;

or

  • 1 acute illness with systemic symptoms;

or

  • 1 acute complicated injury
 Moderate

(Must meet the requirements of at least 1 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)

  • Any combination of 3 from the following:
    • Review of prior external note(s) from each unique source*;
    • Review of the result(s) of each unique test*;
    • Ordering of each unique test*;
    • Assessment requiring an independent historian(s)

or

Category 2: Independent interpretation of tests

  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

or

Category 3: Discussion of management or test interpretation

  • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)
 Moderate risk of morbidity from additional diagnostic testing or

treatment

Examples only:

  • Prescription drug management
  • Decision regarding minor surgery with identified patient or procedure risk factors
  • Decision regarding elective major surgery without identified patient or procedure risk factors
  • Diagnosis or treatment significantly limited by social determinants of health
99205

99215

 High High

  • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;

or

  • 1 acute or chronic illness or injury that poses a threat to life or bodily function
 Extensive

(Must meet the requirements of at least 2 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)

  • Any combination of 3 from the following:
    • Review of prior external note(s) from each unique source*;
    • Review of the result(s) of each unique test*;
    • Ordering of each unique test*;
    • Assessment requiring an independent historian(s)

or

Category 2: Independent interpretation of tests

  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);

or

Category 3: Discussion of management or test interpretation

  • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)
 High risk of morbidity from additional diagnostic testing or treatment

Examples only:

  • • Drug therapy requiring intensive monitoring for toxicity
  • Decision regarding elective major surgery with identified patient or procedure risk factors
  • Decision regarding emergency major surgery
  • Decision regarding hospitalization
  • Decision not to resuscitate or to de-escalate care because of poor prognosis

Prolonged Services

Prolonged Service With Direct Patient Contact (Except with Office or Other Outpatient Services)

The following table illustrates the correct reporting of prolonged physician or other qualified health care professional service with direct patient contact in the inpatient or observation setting beyond the usual service time.

Total Duration of Prolonged Services Code(s)
less than 30 minutes Not reported separately
30-74 minutes
(30 minutes – 1 hr. 14 min.)		 99356 X 1
75-104 minutes
(1 hr. 15 min. – 1 hr. 44 min.)		 99356 X 1 AND 99357 X 1
105 or more
(1 hr. 45 min. or more)		 99356 X 1 AND 99357 X 2
or more for each additional 30 minutes.

 

 

Prolonged Service Without Direct Patient Contact

Total Duration of Prolonged Services Without Direct Face-to-Face Contact Code(s)
less than 30 minutes Not reported separately
30-74 minutes
(30 minutes – 1 hr. 14 min.)		 99358 X 1
75-104 minutes
(1 hr. 15 min. – 1 hr. 44 min.)		 99358 X 1 AND 99359 X 1
105 or more
(1 hr. 45 min. or more)		 99358 X 1 AND 99359 X 2
or more for each additional 30 minutes.

 

 

Prolonged Clinical Staff Services With Physician
or Other Qualified Health Care Professional Supervision

The table below illustrates the correct reporting of prolonged services provided by clinical staff with physician supervision in the office setting beyond the initial 45 minutes of clinical staff time.

Total Duration of Prolonged Services Code(s)
less than 45 minutes Not reported separately
45-74 minutes
(45 minutes – 1 hr. 14 min.)		 99415 X 1
75-104 minutes
(1 hr. 15 min. – 1 hr. 44 min.)		 99415 X 1 AND 99416 X 1
105 or more
(1 hr. 45 min. or more)		 99415 X 1 AND 99416 X 2
or more for each additional 30 minutes.

 

 

Prolonged Service With or Without Direct Patient Contact
on the Date of an Office or Other Outpatient Service

Total Duration of New Patient Office or Other Outpatient Services (use with 99205) Code(s)
less than 75 minutes Not reported separately
75-89 minutes
(45 minutes – 1 hr. 14 min.)		 99205 X 1 and 99XXX X 1
90-104 minutes
(1 hr. 15 min. – 1 hr. 44 min.)		 99205 X 1 and 99XXX X 2
105 or more
(1 hr. 45 min. or more)		 99205 X 1 and 99XXX X 3
or more for each additional 30 minutes.
Total Duration of Established Patient Office or Other Outpatient Services (use with 99215) Code(s)
less than 55 minutes Not reported separately
55-69 minutes
(45 minutes – 1 hr. 14 min.)		 99215 X 1 and 99XXX X 1
70-84 minutes
(1 hr. 15 min. – 1 hr. 44 min.)		 99215 X 1 and 99XXX X 2
85 or more
(1 hr. 45 min. or more)		 99215 X 1 and 99XXX X 3
or more for each additional 30 minutes.