CPT E/M codes are changing January 1, 2021. This webinar unpacks those changes for you, outlining everything you need to know including: How to navigate all the changes What these mean for reimbursement What you need to know to make sure your providers and coders are ready.

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2. CPT Changes
Evaluation and Management (E/M)
Office or Other Outpatient Services
Prolonged Services
www.ama-assn.org
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3. Evaluation and Management Guidelines
TIME
• Not for emergency department levels
• Different service categories use time differently
• Helps determine level of E/M services
• 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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4. Evaluation and
Management
Guidelines
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SERVICES REPORTED
SEPARATELY
• Any specifically identifiable
procedure or service
performed on date of service
may be reported separately
• May need to report patient’s
condition required significant
separate E/M service
• Circumstance may be reported
by adding modifier 25 to level
of service

5. Office or Other Outpatient E/M Services
History and/or Examination – medically appropriate history and/or physical exam
• Scope is determined by health care professional reporting the service
• Care team may collect for physician
Number and Complexity of Problems Addressed at Encounter –
multiple new or established conditions may be addressed at the same time
Problem Problem Addresed Minimal Problem
Stable, Chronic Illness Self-limited or Minor Problem Acute, Uncomplicated Illness or Injury
Test External Independent Historian
Independent Interpretation Appropriate Source Risk
Morbidity Social Determinants of Health Acute, Complicated Injury
Acute Illness with Systemic Symptoms
Chronic Illness with Exacerbation, Progression, or Side Effects of Treatment
Undiagnosed New Problem with Uncertain Prognosis
Chronic Illness with Severe Exacerbation, Progression, or Side Effects of Treatment
Acute or Chronic Illness or Injury that Poses a Threat to Life or Bodily Function
External Physician or Other Qualified Healthcare Professional
Drug Therapy Requiring Intensive Monitoring for Toxicity
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6. Instructions for
Selecting a Level of
Office or Other
Outpatient E/M
Service
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• Medical Decision Making
• Establishing Diagnoses
• Assessing Status
• Selecting Management
Option

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8. CODES
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9. Evaluation and Management
Office or Other Outpatient Services
New Patient
99202 - Office or other outpatient visit, straightforward medical decision
time: 15-29 minutes
99203 - Office or other outpatient visit, low level medical decision
time: 30-44 minutes
99204 - Office or other outpatient visit, moderate level medical decision
time: 45-59 minutes
99205 - Office or other outpatient visit, high level medical decision
time: 60-74 minutes
Established Patient
99211 - Office or other outpatient visit, where a physician or other qualified health professional,
is not necessary
99212 - Office or other outpatient visit, straightforward medical decision
time: 10-19 minutes
99213 - Office or other outpatient visit, low level medical decision
time: 20-29 minutes
99214 - Office or other outpatient visit, moderate level medical decision
time: 30-39 minutes
99215 - Office or other outpatient visit, high level medical decision
time: 40-54 minutes 9

10. Prolonged Services
With Direct Patient Contact (except with office or other outpatient services
99202-99215)
99354 - Prolonged service(s) with direct patient beyond time of usual service,
first hour
99355 - each additional 30 minutes
Use 99355 in conjunction with 99355
99356 – Prolonged service of face-to-face time in unit/floor time in hospital or
nursing facility, first hour
99357 – each additional 30 minutes
Use 99357 in conjunction with 99356
Without Direct Patient Contact
99358 – Prolonged service before/after direct patient care, first hour
99359 – each additional 30 minutes
Use 99358 in conjunction with 99359
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Evaluation and Management

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www.ama-assn.org

12. Evaluation and Management
Prolonged Clinical Staff Services with Physician or other Qualified Health Care
Professional Supervision
99415 – Prolonged clinical staff service in office or outpatient setting, first hour
99416 – each additional 30 minutes
Use 99415 in conjunction with 99416
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Prolonged Service With or Without Direct Patient Contact on the Date of an
Office or Other Outpatient Service
99XXX – Prolonged clinical staff service in office or outpatient setting, first hour
Use 99XXX in conjunction with 99205, 99215)

13. Evaluation and Management
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www.ama-assn.org

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www.ama-assn.org

15. Transitioning to 2021 E/M Coding Guidelines
1. Identify a project lead: A project lead can help make the transition to the updated guidelines
smoother by educating staff on the changes and the practice’s internal reporting policies.
2. Schedule team preparation time: Practice leaders will benefit from scheduling time for in-person
meetings with physicians, clinical staff, and administrative personnel, to review the E/M changes and
address questions.
3. Update practice protocols: Physician practices will need to update their procedures and protocols to
align with the new guidelines. The AMA recommends that practices begin this process earlier rather
than later.
4. Consider coding support: Beginning January 1, 2021, physicians will have to adjust to significant
coding changes pertaining solely to the E/M office and outpatient category of codes. Coding staff can
educate providers and other non-coding staff on the changes.
5. Be aware of medical malpractice liability: Although the 2021 guidelines should lessen
documentation requirements for E/M office visits, physicians should continue to carefully document
their work to protect themselves from medical malpractice suits, AMA advises.
6. Guard against fraud and abuse law infractions: Physicians should continue to take steps to prevent
inadvertent overbilling.
7. Update your compliance plan: As practices undergo the transition to the new E/M guidance, they
must ensure that protocols and procedures remain consistent with their current compliance plans.
8. Check with their electronic health record (EHR) vendor: Practices should contact their EHR vendor to
confirm their schedule for implementing the E/M office visit code changes.
9. Assess financial impact: Practices can perform prospective financial analyses to prepare for potential
increases or decreases in revenue as a result of the E/M changes.
10. Understand additional employer, payer, medical liability coverage requirements: Payers may still
require clinical documentation above and beyond the new E/M office visit coding guidelines.
15https://acdis.org/articles/news-ama-issues-checklist-transitioning-2021-em-coding-guidelines

16. CPT Resources
https:// www.ama-assn.org /system/files/2019-06/cpt-office-prolonged-
svs-code-changes.pdf
https://acdis.org/articles/news-ama-issues-checklist-transitioning-2021-
em-coding-guidelines
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17. CONTACT
Ashley.Giaquinta@careoptimize.com
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