Skip to main content

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.


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

Popular posts from this blog

Usage of CPT Index - Instructions

The alphabetic index is not a substitute for the main text of the CPT codebook. Even if only one code is present, the coder must refer to the main term to ensure that the code is selected accurately and correctly to identify the services rendered. Main Terms The index is organized by main terms. Each main term can stand alone or can be followed by up to three modifying terms. There are four primary classes of main entries, Procedures or Services - E.g, Scopic, Anastomosis, Splint, Opening Organ or Other Anatomical Site - E.g, Knee, Arm, Ear, Tibia, Colon Conditions - E.g, Abscess, Entropion, Tetralogy of Fallot. Synonyms, Eponyms, and Abbreviations. - ECG, EEG, PET, Brock Operations, Clagett Procdures Modifying Terms The main term may be followed by up to three indented terms that modify the terms they follow. EG. The main term "Endoscopy" is subdivided by the anatomical sites in which the procedure is used. And within these anatomical sites, the specific purpose of the pr

Additional Information About Modifiers

Sequencing of modifiers  How can that be if the modifiers used were accurate?  There is an order to reporting modifiers and there are three categories that modifier usage fall under:  1. Pricing  Pricing modifiers are always sequenced “before” payment modifiers and/or location modifiers.   The only exception to this rule is when a global surgery package is involved.  For example, you would code modifier 58 first and modifier 82 second in a global surgery.  A few examples of pricing modifiers are: 22, 26, 50, 52, 53, 62, 80, and P1-P6.   2. Payment   Payment modifiers alert the insurance carrier that there is a special situation within the claim  Some examples of payment modifiers would be: 24, 25, 51, 57, 58, 59, 76, and 78.  3. Location  Examples of location modifiers are: E1-E4, FA, F1-F9, LC, LD, LT, RT, RC, TA, and T1-T9.  The general order of sequencing modifiers is ( 1) pricing (2) payment (3) location. Location modifiers, in all coding situations, are coded “last”.  If you code

Evaluation and Management (E/M) Services - Domiciliary or Rest Home Environment

Domiciliary, Rest Home, or Custodial Care Services CPT codes 99324 - 99337 Domiciliary, Rest Home (e.g. Boarding Home), or Custodial Care Services, are used to report E/M services to individuals residing in a facility which provides room, board, and other personal assistance services, generally on a long-term basis.  These codes are also used to report E/M services in an assisted living facility. The facility’s services do not include a medical component. A home or domiciliary visit includes a patient History, Physical Examination and Medical Decision Making in various levels depending upon a patient’s needs and diagnosis.  The visits may also be performed as counseling and/or coordination of car, when medically necessary outside the office environment and are an integral part of a continuous of the patient's care.  The patients seen may have chronic conditions, may be disabled, either physically or mentally, making access to a traditional office visit very difficult, or may have l