by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Dec 8th, 2020

Reporting a CPT code for an evaluation of a patient is based on time and if the patient is a new or established patient. Evaluation and Management codes are different than other codes, so it is important to understand how they are used. Prior to 2021 they were based on a point system where the codes were required to meet a specific level of history and exam. The need to score history and exam are being eliminated and beginning January 01, 2021, E&M codes will be based on a medical necessity based system or in other words; medical decision making (MDM) or time. Seeing patients in an office or clinic setting and reporting 99202-99215 are impacted by these changes. The first impact is the deletion of 99201, making 99202 the lowest based office visit. 

2021 E&M codes are based on the following:

CPT® Code Set

With services being reported on time, we will now document the number and complexity of problems addressed at the encounter. Although medically appropriate history and exam will not determine code selection, the entire visit still needs to be documented. For example, if the history and exam findings are pertinent to the visit, it must be documented.   

According to the March 2020 CPT assist "E/M Office or Other Outpatient Visit Revisions for 2021:

Time:" beginning, Jan 01, 2021, the following activities are considered on the day of the encounter whether face-to-face or Non-Face-to-face for office or other outpatient visits when calculating time spent by the physician or other QHP"

• preparing to see the patient (eg, review of tests)

• obtaining and/or reviewing separately obtained history

• performing a medically appropriate examination and/or evaluation

• counseling and educating the patient/family/caregiver

• ordering medications, tests, or procedures

• referring and communicating with other health care professionals (when not separately reported)

• documenting clinical information in the electronic or other health records

• independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver

• care coordination (when not separately reported)

Dental codes are reported under the Diagnostic code set D0120-D0999. Find-A-Code offers crosswalks from CPT to CDT and back again, found under Cross-A-Code on the code information page. 

CDT® Dental Codes ("D" Codes)