It’s important to remember that updates on how to document and code for evaluation and management visits (E/M) visits cannot always be found in this year’s CPT® code book. For the latest updates and guidelines, you will want to refer to the 2021 CPT® Errata and Technical Corrections.

Following the start of the new and updated E/M Guidelines in January, the American Medical Association received provider feedback about the following codes:

  • Office or other outpatient: CPT® codes 99202-99215
  • Prolonged services: CPT® codes 99354-99356 and 99417

To clear up any confusion, the AMA CPT® Editorial Panel approved changes to the guidelines and they were posted on March 9, 2021, but are retroactive to January 1, 2021.

Here’s a brief overview on what’s new from the 2021 CPT® Errata and Technical Corrections:

  1. Two modifications to the general E/M guidelines explain the following concepts:
    • Activities that do not count towards a time-based visit.
    • Separately reported tests and interpretations.
  2. The rest of the changes apply exclusively to MDM-based office visits:
    • Expansion of the number and complexity of problems addressed guideline. It expounds on the concept of morbidity and explains how risk is defined for this element (risk from the condition), which is distinct from the risk associated with management (Risk element).
    • Modification of the instructions for selecting a level of office or other outpatient services to provide more information on when to count a provider ordered test.The new expansions further clarifies the need for documentation when a test is considered but not performed after shared decision making.
    • Addition of five new MDM decisions, which are:
      • Analyzed – for reporting tests in the data column.
      • Unique – what constitutes a unique test and unique source.
      • Combination of data elements – allows different data elements to be summed.
      • Surgery – minor vs. major, elective vs. emergency, risk factors
    • Revision of four MDM definitions to more comprehensively explain the following terms:
      • Drug therapy requiring intensive monitoring for toxicity
      • Independent historian
      • Risk
      • Test

It is important to remember to check the 2021 CPT® Errata and Technical Corrections periodically, especially with this year’s additions to E/M coding guidelines. You can access the 2021 CPT® Errata and Technical Corrections directly here: https://www.ama-assn.org/system/files/2020-12/cpt-corrections-errata-2021.pdf