The use of time as the determining factor for code choice for office and outpatient visits has been modified significantly in 2021.ĭifferent E/M codes count time differently, so it is necessary to understand the rules for each type of E/M service. The evaluation and documentation of the elements of the history and physical examination are left to the discretion of the provider, requiring pertinent elements to the specific patient but not encouraging or adding credit to a service for collecting data on multiple bullet points that are not pertinent to the patient or their presenting problem. The criteria used to determine the level of service provided are different, and the level of service is now determined by either: (1) the level of the medical decision-making (MDM) as defined for each service or (2) the total time for E/M services performed on the date of the encounter.īullets are no longer used to determine the level of service. The reader is referred to the American Medical Association (AMA) website for additional information, as well as the CPT 2021 Professional Code Book.Ĭode 99201 has been deleted, and codes 99202-5 (new patient) and 99211-5 (established patient) have been modified. This article reviews coding changes that took effect on January 1, 2021, and briefly describes the main changes to the E/M codes. If you are providing E/M services, it is important to understand the new codes and report them for the services provided. As value has been shifted to E/M services, values for procedural services are expected to decrease to maintain the Centers for Medicare & Medicaid’s (CMS’s) required budget neutrality. The codes have been revised to more closely reflect how providers provide E/M services and to simplify coding for these services, reducing administrative burden and paperwork for providers. The major CPT change for 2021 is evaluation and management (E/M) coding for office or outpatient visits. There are relatively few changes in endovascular and interventional procedural coding for 2021. This article describes coding changes for endovascular and interventional procedures that took effect on January 1, 2021.