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:

• Watch for further updates from the AMA and CMS from now until the January 1, 2021 implementation date
• For more information regarding this topic, visit:
  • CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes effective January 1, 2021: https://ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
  • CPT® E/M Office Revisions – Level of Medical Decision Making (MDM): https://ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

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.