2021 E/M Guidelines FAQ


AAPC’s senior VP of products answers your questions about coding for office and other outpatient services.

Ever since the release of the new 2021 evaluation and management (E/M) guidelines for office and other outpatient services, AAPC has been conducting numerous trainings through webinars, virtual workshops, conference sessions, online courses, and multiple articles in Healthcare Business Monthly and the Knowledge Center blog. In the May and June magazines, we started to answer your questions about how the E/M guideline changes have affected documentation and coding. In this article, we answer 10 more.

Your Questions Answered

  1. Using the new medical decision making (MDM) table, how would you score out an encounter for a patient who presents for a COVID test in order to return to work?

If the patient was asymptomatic, this would be a straightforward visit. There would be credit given for the one lab test and minimal risk to the patient.

  1. If we perform a urinalysis (unique test ordered) in our office, is this one test we can count toward the data component? We are hearing conflicting answers. I know you cannot count the one test as two (ordered and read). I just want to confirm we can count as one test.

When the new guidelines were originally released, if you billed for a test you could not count it as an order toward data in MDM. With the release of the technical corrections to the 2021 E/M guidelines in CPT®, that guidance was changed. If it is a test only that you are not separately billing the professional component for, you can count it as an order.

  1. If commercial payers are not using the new guidelines, how do we implement this? We can’t have one set of documentation for Medicare and another for commercial payers. Any advice on how to resolve this?

Commercial payers will usually either follow CPT® coding guidelines or Medicare payment policies. Because the 2021 guidelines are printed in CPT® and finalized by the Centers for Medicare & Medicaid Services (CMS) through rulemaking, all payers need to comply with the new coding guidelines, unless they release a payment policy that states otherwise.

  1. We see workers comp patients, and the providers are asking if they can count the creation of the state-mandated documents towards time billing.

There are CPT® codes specific for form completion. See CPT® code 99080.

  1. I’m seeing a jump in levels of service based on total time. Is this going to be normal when we are seeing that medical necessity for the time is documented?

The medical necessity must be supported. If, in an audit, it is found that the time stated does not support the activities performed or time that would be considered medically necessary, it could result in an unfavorable finding by the payer.

  1. Does podiatry follow the new guidelines?

Yes. All specialties reporting codes 99202-99215 will use the new guidelines.

  1. If a physician is doing a prior authorization, does it count in total time?

If the provider is personally calling for the prior authorization on the date of service on which they saw the patient, yes, it would be counted in total time. If performed by clinical staff it would not.

  1. We have a physician who likes to wait and sign her charts a day or two later. She has been told that she cannot bill based on time due to the “date stamp” entered thru the electronic medical record (EMR). Is this correct?

Only count the time performed on the date of the visit, not the time to review and sign the chart on a different day.

  1. Can a level 5 visit be billed even if the patient is stable or not sick, but based on time only?

It would depend on what caused the increase of time to meet a level 5. If the amount of time was required to properly treat the patient, it could be supported. For example, some visits may take longer due to multiple patient or caregiver questions or the review of multiple treatment options. The level 5 will also need to be supported by medical necessity.

  1. Can virtual visits (not telephonic) also be level 5 if decision making or time components are documented?

For Medicare, you can look on the list of approved telemedicine visits at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes. Level 5 visits are on the list. Please check with your other payers for their policies.

For more information: https://www.aapc.com/blog/78427-2021-e-m-guidelines-faq-july/



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