APMA News - September/October 2020 - 28

Reimbursement

2021 OFFICE / OTHER OUTPATIENT
EVALUATION AND MANAGEMENT

Significant changes are coming to the guidance used to select the level of office/
®
99201-99215).
other outpatient
Evaluation
and Management
codes (CPT
By APMA
Coding
Committee(E/M)
Members
R. Alex
Dellinger, DPM;
Effective January 1, 2021, the
level
of
office/outpatient
E/M
services
be DPM
Mitchell Hilsen, DPM; and Jonathanwill
Huey,
determined by either medical decision making only or total time only; providers
will no longer consider the three key elements of E/M coding as is currently done.

E/M: An Introduction to the Changes Coming in 2021
CPT 99202-99215
E/M Performed

Documentation
Complete

Decision Making
Level based upon meeting two of
the thresholds of:
1. Number and complexity of
problems addressed
2. Amount and/or complexity of
data to be reviewed and analyzed
3. Risk of complications and/or
morbidity or mortality of patient
management
Straightforward
Low
Moderate
High

How to
Determine
the Level
Starting
1/1/21

Total Time
Level based on total time
spent that day in the care
of that patient:

CPT 99202 / 99212
CPT 99203 / 99213
CPT 99204 / 99214
CPT 99205 / 99215

15-29 minutes
30-44 minutes
45-59 minutes
60-74 minutes

CPT 99202
CPT 99203
CPT 99204
CPT 99205

10-19 minutes
20-29 minutes
30-39 minutes
40-54 minutes

CPT 99212
CPT 99213
CPT 99214
CPT 99215

additional
information,
including
webinar or a provider of the same
Evaluation and management (E/M) codes are one Find
of the
not
been seen
by thea provider
explaining
these
changes,
at
www.apma.org/em2021.
major sources of revenue for the average podiatric medical
specialty, in the same practice, or in more than three years.
practice. In brief, current codes are selected based on the levOther series of E/M codes address hospital visits, consultaReference:
AMA CPT Editorial
Procedural
Terminologytions,
(CPT ) istelephone
copyright 1966,
1973, 1977, 1981,visits,
1983-2019
els of patient history,
the physical
exam,Panel.
andCurrent
the level
of medor1970,
telemedicine
and even home visby the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
ical decision making. The more complex the problem(s), the
its. The rules for reimbursement on these series vary greatly
more complex the exam is likely to be, and thus the more
from payer to payer.
complex the management, which leads to higher-level codes
It is a challenge for podiatrists to qualify for higher levels of
and higher reimbursement. There are different code series
reimbursement due to the stringent requirements for exam
based on the location of the service and whether the patient
elements that many times exceed our scope of practice. For
is new or established, or, in some cases, whether the encounexample, new patient codes CPT 99204 and 99205 require
ter is initial versus subsequent.
detailed and complete exams to qualify for reimbursement,
For a quick review, patient encounters in the office setting
including organ system exams, which are clearly out of scope
are either CPT® 99201-99205 for a new patient visit, or
for podiatrists. A podiatrist may potentially qualify for code
CPT 99211-99215 if the patient is established to the pracCPT 99204 and 99205 based on time, but that is a topic for
tice. A new patient encounter is defined as a patient who has
another article.
®

28 APMA News September/October 2020

http://www.apma.org/em2021

APMA News - September/October 2020

Table of Contents for the Digital Edition of APMA News - September/October 2020