In its February 2019 meeting, the AMA CPT Editorial Panel has approved revised guidelines for new and established office or outpatient visit codes 99202-99215 that would eliminate history and examination as key components to select the E/M service level. Additional E/M documentation changes include the deletion of level one new outpatient visit code 99201, and revisions to codes for prolonged services with or without patient contact .

History and Exam Are Required, but Not Scored

The approved revisions to 99202-99215 require that a medically appropriate history and examination be performed: beyond this requirement, the history and exam do not effect coding. Instead, the E/M service level is chosen either by the level of medical decision making (MDM) performed, or by the total time spent performing the service on the day of the encounter.

The approved changes by the AMA CPT Editorial Panel anticipate revisions to E/M documentation guidelines proposed late last year by the Centers for Medicare & Medicaid Services (CMS) for implementation in 2021, which similarly exclude history and exam when selecting a service level for office or outpatient visits.

Additionally, the Editorial Panel approved revisions to the MDM elements associated with codes 99202-99215:

• “Number of Diagnoses or Management Options” is changed to “Number and Complexity of Problems Addressed”
• “Amount and/or Complexity of Data to be Reviewed” is changed to “Amount and/or Complexity of Data to be Reviewed and Analyzed”
• “Risk of Complications and/or Morbidity or Mortality” is changed to “Risk of Complications and/or Morbidity or Mortality of Patient Management”

The Editorial Panel also approved a revised definition of time, as associated with 99202-99215, from “typical face-to-face time” to “total time spent on the day of the encounter.”

Additional E/M Documentation Changes

Other E/M documentation changes approved by the AMA CPT Editorial Panel include:

• Restructuring E/M guidelines into three sections:
  • Guidelines Common to All E/M Services
  • Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care and Home E/M Services”
  • Guidelines for Office or Other Outpatient E/M Services, to distinguish the new reporting guidelines for the Office or Other Outpatient Services codes 99202-99215
• Adding new guidelines that are applicable only to Office or Other Outpatient codes (99202-99215); adding a Summary of Guideline Differences table of the differences between the different sets of guidelines
• Revising existing E/M guidelines to ensure there is no conflicting information between the different sets of guidelines
• Adding definitions of terms associated with the elements of MDM applicable to codes 99202-99215
• Adding a MDM table that is applicable to codes 99202-99215
• Defining total time associated with codes 99202- 99215
• Adding guidelines for reporting time when more than one individual performs distinct parts of an E/M service
• Deletion of code 99201

The Editorial Panel will share its approved E/M documentation changes with CMS for review, and possible implementation in the Medicare Physician Fee Schedule for 2020 and 2021. What this means is that the elimination of history and exam as key components when selecting an E/M service level for 99202-99215 is almost certain to become a reality no later than 2021. This should reduce the overall documentation burden for providers, but the additional emphasis on MDM means that this element (or time) will need to be documented scrupulously to support the chosen level of service.

Prolonged Services See Some Changes

The Editorial Panel also approved the revision of codes 99354, 99355 to exclude reporting of Office and other Outpatient Services codes, revision of 99356 to include observation, and the addition of a new code (not yet designated) to report prolonged office or other outpatient E/M services