Orthopedic Coding Alert

Here’s why people are already asking about prolonged services codes.

A change is going to come soon to office/outpatient evaluation and management (E/M) coding. After months of theorizing and speculating, the time to act on this information is nigh.

With the new year just a couple of months away, everyone is going to have to get used to a lot of new rules — and code descriptors — when they report office/outpatient E/Ms in 2021.

Help’s here: We’ve got all the info and expert input you need to help make the transition as smooth and seamless as possible. Read on for a breakdown on all the new, revised, and deleted office/outpatient E/M codes for 2021.

2021 Means the End of 99201

You’ve been hearing all year about the massive overhaul in store for E/M office/outpatient services in 2021. However, it’s only when you get a look at the actual code descriptions that this seismic shift within the E/M bedrock becomes a reality.

To start, you’ll want to remind yourself that the last days of code 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) are among us. With the deletion of 99201, you’ll encounter a revised code description for the new bottom-level new patient E/M office/outpatient visit code, 99202:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter)

You can see right off the bat that this is not your father’s typical E/M code description. Most apparent is the lack of key elements listed. Since office/outpatient E/M visits in 2021 will focus exclusively on time or medical decision making (MDM), the code descriptions have been revised accordingly. Now, you can see the code description in 99202 includes just the essentials: MDM level and a total time. Furthermore, the history and exam portions of the visit are to be documented as “medically appropriate,” but are not involved in the calculation of your code selection.

“Keep in mind that the overriding factor is that the level of care be appropriate for the patient’s presenting problem(s),” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey. “Although the history and exam are not included in the level calculation, the medical necessity of the presenting problem(s) are established through the documented “medically appropriate” history and exam,” explains Cobuzzi.

The remaining new patient E/M office/outpatient visit codes following suit with their respective changes to time and MDM:

• 99203 (…low level of medical decision making…30-44 minutes of total time)
• 99204 (…moderate level of medical decision making…45-59 minutes of total time)
• 99205 (…high level of medical decision making…60-74 minutes of total time)

Get Up to Speed on New Descriptors

Before breaking down the code descriptors for the established patient set of E/M office/outpatient codes, take note of what’s fundamentally different about the new code description for 99211:

• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal…)

You can see the code description doesn’t even bother to include an MDM level or total time estimate. Since it’s the default code for any service that doesn’t qualify for at least 10 minutes of total time spent or a straightforward MDM, you’ll opt for 99211. Now, have a look at the remaining respective established patient codes: