E&M code updates of 2021
Medicare and Medicare Advantage plans are adopting the new E&M codes starting from 01/01/2021. However commercial insurances usually follow CMS and AMA guidelines, they are not required to adopt the new changes.
Key takeaways
- 99201 and 99211 are obsolete for 2021
- ALL E&M codes should be coded based on time spent or MDM (Medical decision making)
Time spent is defined as total time spent, including non-face-to-face (documentation) work done on that day.
Changes in time range
CPT Code | Time range (in mins) | MDM | Non-Facility fees 2020 | NON-FACILITY FEES 2021 | Facility fees 2020 | FACILITY FEES 2021 |
|---|---|---|---|---|---|---|
99202 | 15-29 | Straight forward | $77.23 | $69.04 | $51.61 | $46.13 |
99203 | 30-44 | Low | $109.35 | $106.14 | $77.23 | $78.07 |
99204 | 45-59 | Moderate | $167.10 | $159.36 | $132.09 | $127.75 |
99205 | 60-74 | High | $211.13 | $210.66 | $172.51 | $173.88 |
99212 | 10-19 | Straight forward | $46.20 | $54.20 | $26.35 | $34.20 |
99213 | 20-29 | Low | $76.15 | $86.78 | $52.33 | $63.23 |
99214 | 30-39 | Moderate | $110.44 | $122.91 | $80.48 | $93.23 |
99215 | 40-54 | High | $148.33 | $172.27 | $113.68 | $137.75 |
Providers should be conscious in documenting the time spent on each encounter. Example – If a provider sees twenty patients per day spend an average 35 Mins per patient will equals to 11.6 hours which exceeds a typical eight-hour workday and could be remarked as a red flag for a payer unless the provider works 12 hours a day.
The following elements are required for Medical decision making(MDM)
- Number/complexity of the problems during the office visit
- Amount/complexity of data to review and analyze
- Risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problems, diagnostic procedures, treatments.
Prolonged services:
If the time spent by the provider exceeds 75 minutes for a new patient and 55 minutes for an established patient, add-on code 99417 can be used to indicate prolonged services for each 15 minutes with E&M code (99205 or 99215) which pays $30 more for prolonged services.
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