E&M code updates of 2021

Medicare and Medicare Advantage plans are adopting the new E&M codes starting from 01/01/2021. However commercial insurances usually follow CMS and AMA guidelines, they are not required to adopt the new changes.
 
Key takeaways
  1. 99201 and 99211 are obsolete for 2021
  2. ALL E&M codes should be coded based on time spent or MDM (Medical decision making)
Time spent is defined as total time spent, including non-face-to-face (documentation) work done on that day.
Medical Billing Service

Changes in time range

CPT Code

Time range (in mins)

MDM

Non-Facility fees

2020

NON-FACILITY FEES

2021

Facility fees

2020

FACILITY FEES

2021

99202

15-29

Straight forward

$77.23

$69.04

$51.61

$46.13

99203

30-44

Low

$109.35

$106.14

$77.23

$78.07

99204

45-59

Moderate

$167.10

$159.36

$132.09

$127.75

99205

60-74

High

$211.13

$210.66

$172.51

$173.88

99212

10-19

Straight forward

$46.20

$54.20

$26.35

$34.20

99213

20-29

Low

$76.15

$86.78

$52.33

$63.23

99214

30-39

Moderate

$110.44

$122.91

$80.48

$93.23

99215

40-54

High

$148.33

$172.27

$113.68

$137.75

Providers should be conscious in documenting the time spent on each encounter. Example – If a provider sees twenty patients per day spend an average 35 Mins per patient will equals to 11.6 hours which exceeds a typical eight-hour workday and could be remarked as a red flag for a payer unless the provider works 12 hours a day.
 
The following elements are required for Medical decision making(MDM)
  • Number/complexity of the problems during the office visit
  • Amount/complexity of data to review and analyze
  • Risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problems, diagnostic procedures, treatments.
Prolonged services:

If the time spent by the  provider exceeds 75 minutes for a new patient and 55 minutes for an established patient, add-on code 99417 can be used to indicate prolonged services for each 15 minutes with E&M code (99205 or 99215) which pays $30 more for prolonged services.

    Contact Medical Billing Specialist

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