Ring in the new year with improvements in office visit coding and documentation!

December 21, 2020  //  FOUND IN: Updates & Resources

Effective Jan. 1, 2021, the Office Visit Evaluation and Management (E&M) code selection is simplified to reduce documentation burden and allow providers to focus on patient care. Onerous restrictions including who can document the history, and counting only time spent in counseling, are eliminated.  Emphasis is shifted from counting elements of history and physical examination to determining complexity of problems assessed and management options considered.  

Highlights include:

  • Level 1 new patient office visit code (99201) was deleted.
  • History and physical exam elements are no longer required for code selection and may be documented as needed for patient care.
  • Visits levels are to be selected based on Medical Decision Making (MDM) or Time
  • MDM definitions are refined to focus on patient condition and treatment on date of visit.
  • Time requirement now includes face to face and non- face to facework on the day of the visit.

These changes are specific to outpatient E&M services (99202 – 99215) only. Consults, inpatient, ED and other E&M service codes are under review and changes are expected in 2023.

Providers, be sure to review these tools to assist with the changes:

Have a safe holiday and please send any questions to Revenue Cycle Compliance and Education  Med-revcycle-rce@med.umich.edu.