2021 Evaluation and Management (E/M) Guideline Changes

Attention: All Providers Effective Date: January 1, 2021 Call to action: Evaluation and Management (E/M) Guidelines for new and established patient office visits and other outpatient services have gone through substantial revisions by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS).

These changes are effective on January 1, 2021 and only affect the new and established patient office visits and outpatient codes (CPT 99201 – 99215).
Code 99201 will be eliminated.
The History and Physical Examination are no longer elements in the selection of office visit or other outpatient service codes.
Providers have the option to base their services on either the total time for E/M services performed on the date of the encounter OR the level of medical decision making (MDM) as defined for each service.
Prolonged service code CPT 99417 has been added (List separately in addition to CPT codes 99205 and 99215).

How this impacts providers:

Providers must prepare in advance for these new changes: The new E/M Guidelines are not optional and are effective immediately beginning on January 1, 2021
A determination must be made by the provider regarding which option E/M services will be based upon:
- Total Time or;
- Medical Decision Making (MDM)
Providers should confirm with their existing electronic medical record (EMR) vendor that current documentation templates can be aligned with the new E/M Guidelines
Provider staff involved in claim submission will need education and training on the new E/M Guidelines

Next steps for providers:

Watch for further updates from the AMA and CMS from now until the January 1, 2021 implementation date
For more information regarding this topic, visit:
- CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes effective January 1, 2021: https ://ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
- CPT® E/M Office Revisions - Level of Medical Decision Making (MDM): https://ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.