Documentation requirements for E/M visits will also be revised to include two separate sets of reporting guidelines:
The table below highlights several major differences in reporting guidelines for E/M visits that went into effect on January 1, 2021
Question |
Office/Outpatient E/M Visits (99202-99205, 99211-99215, 99417, G2212) |
All Other E/M Visits (e.g., consultation, inpatient, observation, nursing home, emergency department visits) |
Which reporting guidelines apply to E/M services? |
New: Code selection is based on medical decision making OR total time on the date of encounter. |
No change: The 1995 and 1997 E/M documentation guidelines continue to apply to all other E/M services not furnished in the office or other outpatient setting. |
Are history and physical examination (H&P) required elements?
|
New: History and/or examination is required only as medically appropriate for all levels of both new and established patient codes. |
No change: The four categories of H&P (problem focused, expanded problem focused, detailed, and comprehensive) are still applicable in E/M code selection. |
When using time for reporting, how should it be used for code selection? |
New: Code selection is based on total face-to-face and non-face-to-face time of the billing provider on the date of the encounter. |
No change: Time may only be used for code selection when counseling and/or coordination of care dominates the service. |