E/M 2021 Changes – History and Exam

History and exam for new and established patient visits:

• CPT^® revised the definitions of and documentation requirements for new and established patients starting in 2021. This effects codes 99202–99215 only.
• 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, this wish comes true. Codes 99202—99215 may be selected based on total time spent by the billing clinician or medical decision making.

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