Evaluation and Management (E/M) services are the most frequently reported CPT® codes and they are used by almost every specialty. When changes to some of these codes occur, the impact ripples throughout health care. Every year, we know to look for new/revised/deleted CPT codes and to update processes and systems to incorporate those changes. In 2021, the changes will be more important than usual for practice that report office/outpatient E/M codes.

The CPT codes that currently describe office/outpatient E/M services were established prior to 1992. There are two sets of detailed instructions from the Centers for Medicare & Medicaid Services (CMS) on how to select the level of service:

These documentation guidelines are lengthy and complicated with code selection based on a variety of combinations of the level of history, examination, and medical decision-making (MDM). If most of the encounter is spent on counseling and/or care coordination, then the...

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