Evaluation and Management (E/M) visits will no longer be what they used to be. Effective January 1^st, 2021 the level to be used will be dependent on time or Medical Decision Making(MDM).

We at Taino Consultants Inc. have been studying these changes and as a service to the healthcare community created the following summary:

EVALUATION AND MANAGEMENT (E/M) VISITS:

• 99201 has been deleted.
• E/M level is selected based on medical decision making (MDM) or total time spent
• Documentation of patient history and medical examination would only be required when clinically appropriate, i.e. there is no required level of history or exam for visits

Time

• Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service.
• Except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services (CPTs 99202 – 99205, 99212-99215).
• Time may only be used for selecting the level of the other E/M services when counseling and/or coordination of care dominates the service.
• When prolonged time occurs, the appropriate add-on code may be reported.
• It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).
• The appropriate time should be documented in the medical record when it is used as the basis for code selection.
• Time spent performing separately reported services other than the E/M or psychotherapy service is not counted toward the prolonged services time.
• Prolonged services should be coded using 99354-99355. These codes cover the total duration of face-to-face time spent by a physician or other qualified health care professional on a given date providing prolonged service in the outpatient setting, even if the time spent by the physician or other qualified health care professional on that date is not continuous.
• Physician/other qualified health care professional time includes the following activities, when performed:
• preparing to see the patient (i.e. 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)

Medical Decision Making (MDM)

• Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option.
• Medical decision making in the office and other outpatient services code set is defined by three elements:
  • The number and complexity of problem(s) that are addressed during the encounter.
  • The amount and/or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not separately reported. It includes interpretation of tests that are not separately reported. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter. Data is divided into three categories: • Tests, documents, orders, or independent historian(s). (Each unique test, order, or document is counted to meet a threshold number)
    • Independent interpretation of tests.
    • Discussion of management or test interpretation with an external physician or other qualified healthcare professional or appropriate source
• The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment (s).

Medical Decision Making (MDM) Types

 Other Key Concepts

A patient is considered an outpatient until inpatient admission to a healthcare facility occurs.

New vs Established Patient

Understand that the information presented above highlights only a few areas of the changes and that we recommend you become familiar with these changes and or consult a professional to assist with the incorporation of these changes into your Practice.