Ever since the Office or Other Outpatient visit Evaluation and Management services CPT codes for new and established patient visits (99201 through 99215 and 99211 through 99215 respectively) were introduced by AMA in 1992, the codes have undergone minimal changes in the code description over the years until today.

These codes are distinguished based on the whether the patient is new or established and the level of complexity of the visit.

The complexity of the visit is determined by the physician and other health care providers’ documentation of the patient encounter in their medical records.

There are currently three key components which determine the level of service – History (history of present illness), Examination (face-to-face physical examination of the patient by the physician) and Medical Decision Making (which includes the final assessment of the patient and the physician’s plan of care to treat the patient).

There are three other elements called the “contributing factors” which can also be considered as additional service components in determining the level of service provided. They are documentation of the nature of the presenting problem of the patient, counseling provided by the physician and other health care provider to the patient and/or the family member(s) or caregiver, and coordination of care of the patient’s condition with other physicians.

Today, it is imperative that physicians and other health care providers document the three key components in the medical record to get reimbursement for the services provided by them. Also note, it is not necessary to document the contributing factors for all the patients.

Though AMA has come up with the typical face-to-face time physicians and other health care providers spend (with the patients) for each of the Office or Other Outpatient Evaluation and Management level of services CPT codes, time becomes the deciding factor to select the level of service only if 50% of the total management time is spent by the physician in counseling and in coordinating the care of the patient and this fact is well documented in the medical visit record.

Patient Type CPT Level Code Typical Face-to-Face Time Spent by the Physician as Provided by CPT description
New 99201 10 minutes
New 99202 20 minutes
New 99203 30 minutes
New 99204 45 minutes
New 99205 60 minutes
Established 99211 5 minutes
Established 99212 10 minutes
Established 99213 15 minutes
Established 99214 25 minutes
Established 99215 40 minutes

Apart from the regular Office or Other Outpatient Evaluation and Management Services CPT codes, AMA also introduced the Prolonged Services CPT codes in 1994. These are time-based “add-on CPT codes which can be billed with the Office or Other Outpatient Evaluation and Management CPT codes when the physician spends additional face-to-face time with the patient in providing the services.

CPT Code CPT Code Description
+99354 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service
+99355 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged service

Physician Fee Schedule and Relative Value Unit

Physicians or other health care providers performing the evaluation and management services in an office or other outpatient setting are reimbursed based on CMS’ (Center for Medicare and Medicaid Services) Fee Schedule payment rates for each level of service provided. The physician fee for the level of service provided is based on Medicare RVU (Relative Value Unit). Any service provided by the physicians would require a combination of resources. Medicare has come up with the resource utilization for all physician services which is the basis of the RVUs.

The RVU comprises of three factors – physician work, practice expense and physician malpractice expense resource required to furnish that level of service. As determined by Medicare, Physician Work RVUs accounts for the time, technical skill and effort, mental effort and judgement, and stress to provide a service. Practice Expense RVUs account for the nonphysician clinical and nonclinical labor and administration of the practice, as well as expenses for building space, equipment, and office supplies. Malpractice Expense RVUs account for the professional liability insurance. It is estimated that physician work and practice expense comprise 52 and 44 percent of total Medicare expenditure on physician service respectively

Changes Effective January 1, 2021

CMS has finalized the following changes to the Office or Other Outpatient Evaluation and Management Services CPT code sets effective January 1, 2021 with a view to “reduce the administrative burden, improve payment accuracy, and update this code set to better reflect the current practice of medicine.” The changes, as approved by the CPT Editorial Panel, are as follows:

1.  CPT levels 2 through 4 (new patient type) and CPT levels 1 through 4 (established patient type) will continue to have separate physician fee as against the blended rate as proposed earlier by CMS.

2.  CPT 99201 will be deleted since both CPTs 99201 and 99202 involve straight forward medical decision making and only differ in the history and examination elements.

3.  The code descriptions for levels 2 through 5 for new patient visits and 1 through 5 for established patient visits will be revised.

4.  New time ranges will be introduced for levels 2 through 5 for new and 1 through 5 for established patients as detailed in the below table:

Patient Type CPT Level Typical Face-to-Face Time Spent by the Physician as Provided by CPT description (valid until December 31, 2020) Total time (both face to face and non-face to face) spent by the provider on the date of the encounter, effective January 1, 2021
New 99201 10 minutes Deleted
New 99202 20 minutes 15-29minutes
New 99203 30 minutes 30-44 minutes
New 99204 45 minutes 45-59 minutes
New 99205 60 minutes 60-74 minutes
Established 99211 5 minutes Time not mentioned as the visit does not require the presence of the physician or other qualified health care professional
Established 99212 10 minutes 10-19 minutes
Established 99213 15 minutes 20-29 minutes
Established 99214 25 minutes 30-39 minutes
Established 99215 40 minutes 40-54 minutes

5. Documentation of patient history and physician examination will not be used to determine the level of service provided.

6. Beginning January 1, 2021, Physicians can either use time or medical decision making in arriving at the level of service provided by them.

7. Time, as documented by the physician, can be used to select the appropriate level of service in the office or other outpatient setting whether or not counseling and/or coordination of care dominates the service.

8. As provided by AMA, time for coding purposes includes both physician’s face-to-face time with the patient and non-face-to-face time spent by the physician in the care of the patient. Non face-to-face time can include activities such as obtaining old medical records, counseling the patient or the patient’s family, ordering medications or tests, etc.

9. When medical decision making is used to report the level of service, time documented will not be relevant in the code selection.

10. The concept of Medical Decision Making will not apply to CPT 99211. When a Clinical Staff performs a face-to-face encounter and when the physician’s or another qualified healthcare professional’s time is spent in supervising the clinical staff, the service can be reported with 99211.

11. A new time-based Prolonged Service code will be introduced effective January 1, 2021. Though the Code Set has still not been finalized, this code will only be reported with level 5 (both new and established patients) office or other outpatient evaluation and services management code sets.

12. The time-based code will be based on increments of 15 minutes – (CPT 99XXX – Prolonged office or other outpatient evaluation and management service(s) requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes. List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management Services). The “day of the primary care visit” in the Prolonged Service code description denotes the 24-hour period for the date of service reported for the office or other outpatient service visit.

13. The existing Prolonged Services codes, +99354 and +99355 cannot be reported with Office or Other Outpatient Evaluation and Management Services level 2 through 5 (new patient type) and levels 1 through 5 (established patient type) beginning January 1, 2021. These codes cannot also be reported with the New Prolonged Service code 99XXX.

14. There are no changes in how split or shared service should be reported and billed.

15. A new G code, GPC1X, will be introduced which can be reported with levels 2 through 4 only (both new and established patient types) to describe, “the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care” as documented by CMS in the Federal Register.

HCPCS Code Description
GPC1X Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to patient’s single, serious or complex chronic condition. (Add-on Code, list separately in addition to office/outpatient evaluation and management visit, new or established)

Table depicting changes to the Office and Other Outpatient Services Evaluation and management Services Code Description

New Patient Type:

 

CPT 2019 CPT Code Description 2021 CPT Code Description – Effective January 1, 2021
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.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

Deleted
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

  • An expanded problem focused history;
  • An expanded problem focused examination;
  • Straightforward medical decision making.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.

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.
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

  • A detailed history;
  • A detailed examination;
  • Medical decision making of low complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low-level of medical decision making.

When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.

99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

  • A comprehensive history;
  • A comprehensive examination;
  • Medical decision making of moderate complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.

When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.

99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:

  • A comprehensive history;
  • A comprehensive examination;
  • Medical decision making of high complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making.

When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.

(For services 75 minutes longer, see Prolonged Services 99XXX)

Established Patient Type

CPT 2019 CPT Code Description 2021 CPT Code Description – Effective January 1, 2021
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. Typically, 5 minutes are spent performing or supervising these services. 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.
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  • A problem focused history;
  • A problem focused examination;
  • Straightforward medical decision making.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.

When using time for code selection, 10-19 minutes of total time spent on the date of the encounter.

99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  • An expanded problem focused history;
  • An expanded problem focused examination;
  • Medical decision making of low complexity.

Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making.

When using time for code selection, 20-29 minutes of total time spent on the date of the encounter.

99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  • A detailed history;
  • A detailed examination;
  • Medical decision making of moderate complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.

When using time for code selection, 30-39 minutes of total time spent on the date of the encounter.

99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:

  • A comprehensive history;
  • A comprehensive examination;
  • Medical decision making of high complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making.

When using time for code selection, 40-54 minutes of total time spent on the date of the encounter.

(For services 55 minutes longer, see Prolonged Services 99XXX).

Quintessence View of the Changes

As AMA has rightly called it, this is a historic provision finalized by CMS (Centers for Medicare and Medicaid Services) on November 1, 2019 and we agree.

This calls for a global change in the approach of the physicians, the coders and the payers – the physicians will have to change the way they will start documenting their office and other outpatient services.

EHRs must change to meet the new guideline requirements. Physicians and other health care practitioners should also adapt to the new EHR changes. They do not have to spend time on ticking all boxes in the EHR to ensure the history and the examination is well documented to match the level of service provided by them. They can now start focusing more on the patients. They must ensure they document the total time of the encounter (both face-to-face and non-face-to- face) for the patient visit and appropriately document the medical decision making.

The coders will face the challenge of unlearning the existing Evaluation and Management guidelines for coding and reporting and relearn the new guidelines as provided by AMA and approved by the CPT Editorial Panel. Any deficiencies in the documentation should be duly noticed and taken up with the providers to increase the first-level pass percentage with the payers.

The payers will have to follow the new MPFS effective January 1, 2021. The chances of them denying the claims will be high, but if the physicians document the visits appropriately and if the coders follow the guidelines and report the most appropriate level code as warranted by the medical record, this transition will be smooth.

Impact Assessment

For coding companies, this should result in lesser overheads in training new coders. This will also increase the productivity of the coders and will translate into lower coding costs. Coders will focus on MDMs and that will help them guide the documentation to focus on MDM. All in all, we believe that this will benefit all stakeholders.

Anitha Balasubramanian is currently on the core team of Quintessence Business Services & Solutions. She has deep domain experience of over 23 years in the US HealthCare Coding business. She was amongst the first batch of CPC-certified coders outside the USA.