Is it true that history and exam won’t be required elements for E/M services?

Question:

Is it true that history and exam won’t be required elements for evaluation and management services?

Answer:

That is true for new and established patients in 2021.

CPT is changing the requirements for selecting the level of service for new and established patients in 2021, and CMS has agreed with, and is accepting these changes. It was a major relief for medical practices that CMS rescinded their proposal for a single bundled payment for level 2-4 new patient visit and level 2-4 established patient visits. Instead, CMS accepted the new definitions that will be in the CPT book in 2021.

In 2020 nothing is changing. Continue to use the documentation guidelines to select your level of service for all E/M services.

In 2021, new patient visit code 99201 will be deleted. The level of history and exam will no longer be a factor in selecting the level of service. The CPT book in 2021 will say:

“Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified health care professional reporting the service.”

Instead, a clinician will select the level of service based on time or medical decision making. Time is redefined for 99202—99205 and 99212—99215 to a range, rather than a single threshold value, and no longer requires that counseling dominates the visit. Typical pre – and post – work performed by the billing clinician may be counted in the total time. Calculating the level of medical decision making to select a code is also revised for 2021, with especially big changes in reviewing data.

The E/M rules for all other E/M services is unchanged in 2021, and there are no changes to selecting a level of service for any E/M services in 2020.

Learn more about E/M changes for 2021.

 

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