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Last Modified: 2/1/2021 Location: FL, PR, USVI Business: Part A, Part B

E/M FAQ -- Determining further work-up under number of diagnoses

Changes to office/outpatient E/M services for 2021

NOTICE -- Effective for dates of service on and after January 1, 2021, practitioners will have the choice to document office/outpatient E/M visits via medical decision making (MDM) or time. The Centers for Medicare & Medicaid Services (CMS) is adopting the American Medical Association's (AMA's) Current Procedural Terminology® (CPT®) revised guidance, including deletion of CPT code 99201. The E/M code and guideline changes are specific for office and other outpatient visits and apply to codes 99201-99205 and 99211-99215. Based on the CPT changes, code 99201 is no longer valid for dates of service on and after January 1, 2021, as clinicians may choose the E/M visit level based on either medical decision making or time, both CPT code 99201 and 99202 previously require straightforward medical decision making, therefore the decision was made to delete CPT code 99201.
Click here external pdf file to view details regarding the 2021 changes to office/outpatient E/M services.

This FAQ guidance pertains to office/outpatient E/M services for dates of service prior to January 1, 2021, and all other E/M services regardless of the date of service.

Q. In medical-decision making, how does one determine further work-up under “number of diagnoses”?
A. A key element of the medical-decision making category includes management decisions made by the physician to determine a diagnosis and treatment. Evidence of further work-up within documentation would include indicating a problem is worsening/probable and/or listing possible management options, advice sought, referrals or consultations, and the initiation of or change in treatment.

Number and complexity of problems addressed at the encounter

Effective for dates of service on and after January 1, 2021, the "Number of Diagnoses and Management Options" has been changed to "Number and Complexity of Problems Addressed at the Encounter."
One element in the level of code selection for an office or other outpatient service is the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.