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E/M Guidelines for Office/Outpatient 2021

E/M Guidelines for Office/Outpatient History and Exam

The 2021 E&M Guidelines for Office or Other Outpatient E/M Services will help you understand the revised E/M codes.

The History and/or Examination portion of these E/M guidelines explains that office and other outpatient E/M services include “a medically appropriate history and/or physical examination, when performed.”

The “Medically appropriate” means that the physician or other qualified healthcare professional reporting the E/M determines the nature and extent of any history or exam for a particular service.

Remember that code selection does not depend on the level of history or exam.

The history and exam guidelines for office and outpatient E/M visits also specify that the “care team” may collect information, and the patient (or caregiver) may provide information, such as by portal or questionnaire. The reporting provider must then review that information.

MEDICAL DECESION ON MAKING GUIDELINES

The code selection will be either total encounter time or MDM to select the level of office or other outpatient E/M in 2021, 

In the 2021 MDM guidelines, CPT states that MDM “includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option.” Three elements define MDM for office/outpatient visits in 2021, and they are similar but not identical to the 2020 elements

Table Row 1 Diagnosis

The number and complexity of the problem or problems the provider addresses during the E/M encounter.
  • In 2020, the guidelines instead referred to “the number of possible diagnoses and/or the number of management options.”

Table Row 2 Data

The amount and/or complexity of data to be reviewed and analyzed.” The 2021 guidelines list three categories for data: 
  1. Tests, documents, orders, or independent historians, 
  2. Independent test interpretation, and 
  3. Discussion of management or test interpretation with external providers or appropriate sources. 
The latter term refers to non-healthcare, non-family sources involved in patient management, like a parole officer or case manager.
  • The 2020 MDM guidelines also included the amount and/or complexity of medical records, test, and other information involved, but the 2021 guidelines expand the section significantly

Table Row 3 Risk

The risk of complications and/or morbidity or mortality of patient management decisions made at the visit.” 

The 2021 guidelines make it clear that options considered, but not selected, are still a factor for this element, specifically after “shared” MDM with the patient, family, or both. Examples include deciding against hospitalization for a psychiatric patient with sufficient support for outpatient care or choosing palliative care for a patient with advanced dementia and an acute condition.
  • The 2020 MDM guidelines included comparable wording, but they did not include the reference to shared MDM or the examples found in the 2021 guidelines.

MDM - Medical Decision Making Table

The 2021 MDM table in the CPT E/M guidelines has three main columns with the final column divided into three additional columns
  1. Code
  2. Level of MDM (Based on 2 out of 3 Elements of MDM)
  3. Elements of Medical Decision Making
    • Number and Complexity of Problems Addressed at the Encounter
    • Amount and/or Complexity of Data to be Reviewed and Analyzed
    • Risk of Complications and/or Morbidity or Mortality of Patient Management


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