Provider Alert! 2021 Evaluation and Management (E/M) Guideline Changes

Provider Alert!

Provider Alert! 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:

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.

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