Update & Guidance: 2021 CPT EM Office or Other Outpatient and Prolonged Services Code and Guideline

The Society for Maternal-Fetal Medicine (SMFM) Coding Committee; Steve Rad, MD; David Smith, MBA, CPC; Trisha Malisch, CCS-P, CPC; Fadi Bsat, MD; Vanita Jain, MD

Effective January 1, 2021, the Current Procedural Terminology (CPT) Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and corresponding Prolonged Services Codes have been significantly revised and updated for services delivered during office visits and other outpatient encounters by the American Medical Association (AMA) (https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf). These changes are meant to simplify and improve coding and documentation requirements for physicians and other qualified health professionals (QHP). Here, the SMFM Coding Committee shares an update and guidance on the new code and guideline changes as well as documentation changes of relevance to MFM subspecialists and practices.

In the office or other outpatient setting, components for E/M code selection are based solely on either one of the two following selections-

1. Total time on the day of the encounter
2. Medical decision making (MDM)

You do not need to meet requirements for both. It is important to note that these changes are specific to office or other outpatient codes 99202-99215 only; all other outpatient services (e.g., outpatient consultations 99241-99245, emergency department visit codes 99281-99285) and inpatient/observation services (e.g., 99251-99255, 99221-99223, 99231-99233, 99219-99220) will continue to use previous elements of leveling visits.

Total Time
Beginning with CPT 2021 and except for 99211, time alone may be used to select the appropriate code level (99202-99205, 99212-99215), whether or not counseling and/or coordination of care dominates the service. Nonetheless, the E/M services for which these guidelines apply require a face-to-face encounter with the physician or QHP.

For office or other outpatient services, if the physician or QHP time is spent on the supervision of clinical staff who perform the face-to-face services of the encounter, continue to use 99211. Please refer to AMA guidelines for the definition of a QHP (versus other providers, example MAs, in the office)

For coding purposes, time for these services is redefined as the total time on the date of the encounter. It includes both face-to-face and non-face-to-face time personally spent by the physician and/or QHP on the day of the encounter (see shaded box below).

Of note, for shared split visits (joint physician + QHP visits), only distinct time for each practitioner should be summed (ie, when 2 or more individuals meet with or discuss the patient at the same time, only the time of 1 individual should be counted). Also of note, total time does not include time in activities normally performed by the clinical staff that do not personally require the physician or QHP.

Services reported separately:

Any specifically identifiable procedure or service (i.e., identified with a specific CPT code) preformed on the date of E/M services may be reported separately. As with all time-based codes, time spent performing separately billable services should NOT be counted toward the total time for selecting the E/M code. For example, the time spent performing, interpreting and reporting out the ULTRASOUND or other diagnostic study does NOT count for the time selection with the E/M.  If the provider performs a fetal anatomy ultrasound and reports 76811, you may not include the time the provider spent performing the interpretation and writing the report portion of this specific study in the total time for the E/M service. (If they are not separately reporting 76811 for some reason, however, you can count the interpretation time in the E/M service time calculation).

The physician/QHP will need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant separately identifiable E/M service. This is reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.

Codes for E/M Office or Other Outpatient Services
The following codes are used to report E/M services provided in the office or other outpatient setting when using time for code selection. A patient is considered an outpatient until inpatient admission occurs. A new (as opposed to established) patient is one who has not received any professional services from the physician/QHP or another physician/QHP of the exact same specialty and subspeciality who belongs to the same group practice, within the past 3 years.

New Patient, total time, same date of encounter:
99201 has been deleted.

99202: 15-29 minutes

99203: 30-44 minutes

99204: 45-59 minutes

99205: 60-74 minutes

For services 75 minutes or longer, use Prolonged Services 99417 in addition to 99205, in increments of 15 min.

Established patient, total time, same date of encounter:

99211: E/M of an established patient by clinical staff that does not require the presence of a physician/QHP

99212: 10-19 minutes

99213: 20-29 minutes

99214: 30-39 minutes

99215: 40-54 minutes

For services 55 minutes or longer, use Prolonged Services 99417 in addition to 99215, in increments of 15 min.

Prolonged Services with or without direct patient contact on the date of an office or other outpatient service:

To report prolonged total time (i.e., combined time with and without direct patient contact) provided by the physician or QHP on the same date of service beyond the minimum total time of the highest-level service (99205 or 99215), new code 99417 is used to report each unit of minimum 15 minutes of additional time. Do not report additional units of 99417 for any time unit less than 15 minutes. You may no longer report prolonged services code 99354-99357 with 99202-99215.

For prolonged services without direct face-to-face patient contact and on a different date than the E/M encounter (for example record review prior to or after an in-person visit) see and use codes 99358-99359 as before (SMFM Coding Tip https://www.smfm.org/coding/tips/120-billing-for-non-face-prolonged-services).

Documentation/Macros:

When coding for E/M based on total time, physician/QHP documentation must justify time spent for the visit and must reflect an accurate representation of services rendered. The actual true total time spent on the day of the encounter must be documented precisely. While you are not required to itemize time spent and the CPT instructions do not specify how you are to document the time, the SMFM Coding Committee provides some sample documentation approaches. A more detailed documentation approach may be helpful to avoid scrutiny and need for explanation later, but not required. Remember: For coding purposes, time for these services is redefined as the total time on the date of the encounter. It includes both face-to-face and non-face-to-face time personally spent by the physician and/or QHP on the day of the encounter.

The following are sample detailed macros that can be used in your EMR reporting systems:

Sample 1:

Total time spent on patient care was ___ minutes.

This included the following tasks: preparing to see the patient; history and exam; counseling and educating the patient/family/caregiver; ordering medications, tests or procedures; referral or communication with other healthcare professionals; record documentation; interpretation of tests and communication of results; and care coordination.

Sample 2:

The patient had all her questions answered. She voiced understanding of the plan of care and her satisfaction with our care today. Thank you for the opportunity to participate in the care of Ms. XX YY. Please do not hesitate to contact us if you may have any questions or concerns.

• I spent ___ minutes prior to the visit preparing to see the patient (reviewing medical records and tests).
• I spent ___ minutes face-face-to-face with the patient and/or family members for counseling and coordination of care.  
• I spent ___ minutes after the visit with the patient documenting the visit in the electronic health record and/or communicating with other health care professionals and/or care coordination.
• Total time spent on today’s date of service: ___ minutes.

Patient admitted to hospital:

To report services provided to a patient who is admitted to a hospital in the course of an encounter in the office or other ambulatory facility, both the inpatient and outpatient services should be combined, and an initial hospital care code (99221-99223) should be billed. If the admitting provider is part of a different group practice, the physician who sees the patient in the office may bill their office visit code (99202-99215).

Telehealth

During the pandemic, outpatient telehealth encounters may be treated by payers like face to face. Please check with your payers as this may change in the future.

Medical Decision Making (MDM)

Coding for office or other outpatient visits using MDM is another approach, and has been significantly revised as well. MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option and is defined by 3 elements:

1. Diagnosis. The number and complexity of problems addressed in the encounter (it is no longer necessary to document every diagnosis a patient has received- just those being addressed during that visit).
2. Data. The amount or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and other information that must be obtained, ordered, reviewed, and analyzed for the encounter. Data is divided into 3 categories:
   • Tests, documents, orders, or independent historians. Each unique test, order or document is counted to meet a threshold number.
   • Independent interpretation of tests.
   • Discussion of management or test interpretation with external physician or other QHP or appropriate source.
3. Risk. The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problems, diagnostic procedures, treatments.

Four (4) types of MDM are recognized: straightforward, low, moderate, and high. To qualify for a particular level of MDM, 2 of 3 elements for that level of medical decision making must be met or exceeded.

The concept of the level of MDM does not apply to code 99211. Also, as with the time-based codes, when the physician/QHP is reporting a separate CPT code that includes performance, interpretation and/or report (e.g., ultrasound or other diagnostic test), these elements should not be counted in the MDM data points when selecting a level of office or other outpatient service. See resources below for further information and guidance.

Resources

The SMFM Coding Committee has developed the 2 grids on the following pages for further guidance and coding examples for selecting the appropriate level of Total Time-Based and/or MDM-Based E/M coding according to the 2021 AMA guideline changes. These can serve as quick references in your clinical practice.

These can be found here: https://s3.amazonaws.com/cdn.smfm.org/assets/SMFM_2021_EM_Guidelines.pdf

Coding Examples

1. MFM sees an established patient for an office visit and detailed fetal anatomy survey. She is 20 weeks GA, AMA and has diabetes and chronic HTN. The MFM spends total time of 42 minutes on the date of the encounter addressing the patient’s medical conditions, separate from the ultrasound procedure. A 76811 ultrasound is performed with normal findings, interpreted and report generated and separately billed for.
   • Proper coding, Total Time-Based: 76811, 99215 (40 + minutes) + Modifier 25
   • Macro written in the patient’s chart:

The patient had all her questions answered. She voiced understanding of the plan of care and her satisfaction with our care today. Thank you for the opportunity to participate in the care of Ms. XX YY. Please do not hesitate to contact us if you may have any questions or concerns.

• I spent 10 minutes prior to the visit preparing to see the patient (reviewing medical records and tests).
• I spent 22 minutes face-face-to-face with the patient and/or family members for counseling and coordination of care.
• I spent 10 minutes after the visit with the patient documenting the visit in the electronic health record and/or communicating with other health care professionals and/or care coordination.
• Total time spent on today’s date of service: 42 minutes.

1. MFM sees an established patient in follow up for well controlled GDM A1 at 32 weeks GA. Glucose log and food diary data are reviewed from the prior visit as well as those provided by the patient today. GDM goals, diet and exercise are reviewed. No ultrasound or diagnostic test was performed at this visit. The visit is properly documented in the electronic health record including history and exam, status and severity of the condition, and an assessment and plan of care.
   • Proper coding, MDM-based: Established patient, low complexity. 99213

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