Changes Ahead for Office-Based and Other Outpatient Evaluation and Management Codes

December 2020

Office-Based Codes Cvr

ISMS Overview of Key Updates  

In late 2019, the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel issued new coding guidance for office and other outpatient evaluation and management (E/M) services.

arrowsApplies only to office-based and other outpatient E/M visits (99201 – 99215)

The changes are included in the CPT 2021 code set, and are among the most significant changes made to E/M coding guidance in a quarter century. In developing the new guidance, the CPT Editorial Panel sought to reduce administrative burden; clarify and expand relevant definitions and guidelines; decrease the need for unnecessary or duplicative documentation; and ensure physicians have relevant options for code level selection.

Although not required to do so, public and private third-party payers are strongly encouraged to follow CPT coding conventions and guidance, and payers may adopt these new E/M guidelines beginning in 2021. The Centers for Medicare and Medicaid Services (CMS) announced in their final 2020 Medicare Fee Schedule Rule their intention to align their E/M coding policies with the CPT Editorial Panel changes effective January 2021. Although additional changes could be made once the CMS releases the final 2021 Medicare Fee Schedule Rule, we anticipate the changes highlighted in this document will be adopted by CMS and perhaps other payers as well.

arrowsRemember that third party payers are not required to adopt CPT code modifications, and therefore may not follow the E/M code revisions as presented. Check with individual payers to confirm their latest billing rules.

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