Evaluation and Management CPT Codes

The majority of family physician practices revolve around evaluation and management (E/M) codes. By understanding how to correctly document and code for E/M services, family doctors and other qualified health professionals (QHPs) such as nurse practitioners or physician assistants can maximize remuneration and alleviate the stress associated with audits.

E/M codes are classified according to their complexity and documentation requirements.

The CPT Editorial Panel changed the E/M documentation and coding requirements for office visits effective January 1, 2021, in response to advocacy from the AAFP and other medical specialty groups. These fundamental changes are intended to alleviate administrative load and increase physician time spent on patient care. CMS accepted the CPT revisions and boosted the relative values for an office visit E/M codes, as well as creating a primary care add-on code as part of the Medicare physician pay schedule.

The following are highlights of significant changes:

Elements of the history and physical examination are omitted (when not necessary): The patient history and physical examination are no longer considered for selecting E/M level codes. Physicians should continue to document the patient’s history and physical examination as medically necessary.

The code 99201 is no longer valid: CPT code 99201 has been deactivated and is therefore no longer available for selection as a CPT code.

Guidelines for E/M documentation have been supplanted by medical decision-making (MDM) or total time spent in the office visit E/M codes: The 1995 and 1997 rules for E/M documentation do not apply to office visit E/M codes. Physicians can specify the duration of an office visit in terms of total time or MDM.

**Please keep in mind that these changes will affect solely office visits and outpatient E/M services (CPT codes 99202-99205 and 99211-99215).

CPT Code

Time Range

99202

15-29 minutes

99203

30-44 minutes

99204

45-59 minutes

99205

60-74 minutes

99212

10-19 minutes

99213

20-29 minutes

99214

30-39 minutes

99215

40-54 minutes

 

Prolonged services:

According to CPT, if the total time spent on the date of service exceeds the minimum time required for the maximum level of service (i.e., 99205 or 99215) by at least 15 minutes, physicians can bill for prolonged services using the new add-on CPT code 99417 (“prolonged office or other outpatient evaluation and management service(s) [beyond the total time of the primary procedure selected using total time], requiring total time with or without direct patient contact beyond the usual requirements”). CPT code 99417 may be billed in 15-minute increments and is only applicable when total time is utilized to calculate the level of service. CPT code 99417 should not be billed in fewer than 15-minute increments. Physicians should not combine CPT codes 99354, 99355, 99358, 99359, 99415, or 99416.

CPT code 99417 is not covered by CMS for prolonged services. Rather than that, physicians should use Healthcare Common Procedure Coding System (HCPCS) code G2212 for prolonged services provided to Medicare patients when the total time spent on the date of service exceeds the maximum required time for the primary procedure code selected based on the total time spent on the date of the primary service. G2212 should not be recorded for time intervals less than 15 minutes. Physicians should not bill the HCPCS code G2212 in conjunction with the CPT codes 99354, 99355, 99358, 99359, 99415, or 99416.

Medicare Telehealth

Numerous telehealth services covered by Medicare have been added to the list of new CPT codes for 2021. Category 3 services were added as a result of the COVID-19 pandemic and will remain on the list until the pandemic is eradicated.

Evaluation and Management CPT Codes

90853

Group psychotherapy

96121 (96130-96133, 96136 – 96139 category 3 basis)

Psychological and Neuropsychological testing

99334 – 99335 (99336 – 99337 category 3 basis)

Domiciliary, rest home, or custodial care services with established patients

99347 – 99348 (99349 – 99350 category 3 basis)

Home visits with established patients

99281 – 99285 category 3 basis

Emergency Department Visits, levels 1-5

99315-99316 category 3

Nursing facilities discharge day management

97161-97168, 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507 category 3

Therapy services, physical and occupational therapy, all levels

99238-99239 category 3

Hospital discharge day management

99469, 99472,99476 category 3

Subsequent inpatient neonatal and pediatric critical care

99478-99480 category 3

Continuing neonatal intensive care services

99291-99292 category 3

Critical care services

90952, 90953, 90956, 90959, 90962 category 3

End-stage renal disease monthly capitation payment codes

99217, 99224-99226 category 3

Subsequent observation and observation discharge day management

99483

Cognitive assessment and care planning services

G2211

Visit complexity inherent to certain office/outpatient evaluation and management

G2212

Prolonged services

Surgery CPT Codes for 2021

Surgery: Breast Repair & Reconstruction

19316 – 19323, 19325-19365, 19367-19396

Revised to provide a clearer description of different breast repair & reconstruction techniques, 19324 and 19366 were deleted

11970

Replacement of breast tissue expander with permanent implant

11971

Removal of breast tissue expander without insertion of implant

Surgery: Endoscopy/Arthroscopy

29822 – 29823

Define the difference between limited versus extensive debridement

Surgery: Respiratory

30468

Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)

32405 deleted

32408

Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance when performed

Surgery: Cardiovascular

33741, 33745, 33746

Shunting procedure for congenital cardiac anomalies

33900, 33991

Revised to specify procedure involves the left heart

33995

Insertion of ventricular assist device in the right heart

33992

Removal of the ventricular assist device from the left heart

33997

Removal of a ventricular assist device from the right heart

Surgery: Genitals

55880

Transrectal ablation of malignant prostate tissue using HIFU

+57465

Computer-aided mapping of abnormal areas of the cervix

Surgery: Nervous System

64455, 64479, 64480, 64483, 64484

Revised to be child codes to the parent code 64400

Radiology

71250, 71260, 71270

Revised to include “diagnostic”

71271

Added to report low-dose thorax computed tomography (CT) for lung cancer screening

74425

Revised for clarity, removed “pyelogram, nephrostogram, loopogram”

76145

Report medical physics dose evaluation for radiation exposure that exceeds institutional threshold

Pathology & Laboratory

Several new codes were added to the Therapeutic Drug Assays subsection:

●      80143 Acetaminophen

●      80151 Amiodarone

●      80161 -10, 11- epoxide

●      80167 Felbamate

●      80181 Flecainide

●      80189 Itraconzole

●      80193 Leflunomide

●      80204 Methotrexate

●      80210 Rufinamide

●      80179 Salicylate

81168, 81278, and 81279

Switched from Tier 2 codes to Tier 1 codes

Medicine CPT Codes for 2021

90377

Rabies immune globin code to report heat- and solvent/ detergent-treated human doses, administered intramuscularly

92227 – 92229

Retinal imaging for detection or monitoring of diseases

93241 – 93248

External electrocardiographic recording, converted from category III codes (0295T, 0296T, 0297T, 0298T) to category 1

COVID-19 CPT Codes for 2021

In response to the need to report COVID-19 testing, many of the new codes went into effect in 2020.

86328

Single-step immunoassay antibody detection

86769

Multiple-step immunoassay antibody detection

87635

Infectious agent detection with nucleic acid probe

0202U

Report pathogen detection

87426

Revised to add “fluorescence immunoassay” and to delete “multiple-step method”

87636, 87637, 87811

Distinguish the tests for influenza A, influenza B, and RSV that include SRS-CoV-2 from those that don’t

Behavioral and Mental Health Billing Coding Guide 2021