Question: I billed a 99201 and it was denied. What happened? Are E&M codes no longer valid, or have they changed?
Yes, for 2021 there has been an update to the evaluation and management (E&M) codes including the elimination of code 99201.
What's Changed With the Codes (and What Hasn't)
The codes now for E&M codes range from 99202 through 99205 for a new patient and 99211 through 99215 for an established patient. The only code eliminated was 99201, but all codes have an update to their description and the manner in which you choose the appropriate level of E&M service.
What has not changed is how you choose a new-patient or established-patient code. The codes for new patients (99202-99205) still maintain that a new patient is someone who is new to the office, or has not been seen in three years or longer. An established-patient code (99211-99215) is for the evaluation of any patient seen by the provider within three years. A new injury or new complaint of an existing patient (less than three years) does not constitute a new patient for coding of E&M services.
What the Codes Now Mean
The codes are now described in the following manner:
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision-making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter, (99201 has been deleted; to report use 99202.)
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision-making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision-making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.
99211 Office or other outpatient visit for the evaluation and management of an established patient, and may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision-making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision-making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision-making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.
Why the Changes Benefit You
The prior descriptions indicated providers would spend a typical amount of time face to face with the patient. This has been removed. This statement did not allow providers to use time as a controlling factor for the level of exam and would otherwise be based on three main factors, including history, examination and medical decision-making (severity of the patient's condition).
This protocol often meant that acupuncture providers who might require an hour of history and evaluation for a chronic patient would not qualify for a code higher than 99203, as severity and medical decision-making did not meet the requirements of morbidity or mortality. Even with this lengthy history and other details necessary, the severity and medical decision-making would only allow for a lower-level coding.
Under the new definitions of E&M codes, you may still use medical decision-making or severity as a factor when choosing the code; but may also use time as a deciding factor. What is now considered part of the E&M is not just time face-to-face or medical decision making, but time for the evaluation that includes the time before, during and after the face-to-face time that is part of the evaluation.
For example, many providers may use specific intake forms within an electronic record-keeping system that require the patient to fill out detailed history and complaint forms before the examination. That information is often reviewed before seeing the patient. That time will now count toward the time of evaluation as long as it is done on the same date as the visit.
Time is now a specific parameter to choose the level of E&M and is not just time face-to-face, but represents the total provider time spent on the date of service, including:
- Preparing to see the patient (e.g., review of tests)
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating patient / family / caregiver
- Ordering tests or procedures
- Referring and communicating with other health care professionals (when not separately reported)
- Documenting clinical information in electronic or other health records
- Independently interpreting results (not separately reported) and communicating results to the patient / family / caregiver
- Care coordination (not separately reported)
- Discussing ongoing treatment, lifestyle modifications and preventive health care needs
The protocols for choosing the proper E&M service will maintain medical decision-making as a method to choose the code. For example, a patient with a life-threatening condition may still have an evaluation that would qualify for 99205 (a high-value code), even if it only takes 15 minutes. The difference now is acupuncture providers will no longer be limited to lower-level E&M codes, even when they have to spend considerable time with the patient on evaluation.
I caution that if you spend one hour with every new patient, that may be a style issue. I suggest you not use 99204 and 99205 when there is a minor or self-limited problem, as use of the code would require an explanation of the need for spending such time on a limited condition.
You may wonder, what if you spend less than 10 minutes on an evaluation on a new patient? What code can you use? It would still be 99202, and although you may not have spent 10 minutes, the medical decision-making for 99202 starts with one self-limited or minor problem. Just as the other codes can use medical decision making without the time element, this would, too. If the patient has one self-limited problem or you spend 10-19 minutes on a new patient, it would qualify for use of 99202.
Editor's Note: Have a billing question? Submit it to
; it may be the subject of a future column. For a short video presentation and primer by Sam on the E&M code changes, click here.
Click here for more information about Samuel A. Collins.