CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

E/M 2021 Changes – History and Exam

History and exam for new and established patient visits in 2021

  • CPT® is revising the definitions of and documentation requirements for new and established patients beginning in 2021.
  • There are no changes to these codes or the guidelines in 2020.
  • Other E/M services in different code categories will continue to use the 1995 and 1997 guidelines.

Clinicians have long objected to the bullet counting and systems listing required for high-level E/M services. Sometimes, missing only family history for an 85-year-old patient would cause the visit to be coded at a low level, no matter how complex the patient was. With the addition of electronic health records, everyone agreed that there was often unnecessary and repetitive information in the record, and at times the information was contradictory or unbelievable. Many clinicians thought that complexity should guide code selection. In 2021, they will get their wish. Codes 99202—99215 may be selected based on time or medical decision making.

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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