American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Guidelines for E/M Reporting

Documentation requirements for E/M visits will also be revised to include two separate sets of reporting guidelines:

  • One set for reporting office/outpatient E/M visits
  • One set for reporting all other E/M visits that are not furnished in the office/outpatient setting

The table below highlights several major differences in reporting guidelines for E/M visits effective January 1, 2021.

 

Office/Outpatient E/M Visits
(99202-99205, 99211-99215, G2212)

All Other E/M Visits
(e.g., consultation, inpatient, observation, nursing home, emergency department visits)

Which reporting guidelines apply to E/M services in 2021? New: Code selection is based on medical decision making OR total time on the date of encounter. No change: The 1995 and 1997 E/M documentation guidelines continue to apply to all other E/M services not furnished in the office or other outpatient setting.
Are history and physical examination (H&P) required elements? New: History and/or examination is required only as medically appropriate for all levels of both new and established patient codes. No change: The four categories of H&P (problem focused, expanded problem focused, detailed, and comprehensive) are still applicable in E/M code selection.
When using TIME for reporting, how is time used for code selection? New: Code selection is based on total face-to-face and non-face-to-face time of the billing provider on the date of the encounter. No change: Time may only be used for code selection when counseling and/or coordination of care dominates the service.
When using MDM for reporting, what MDM elements apply for code selection? New: Both new and established patients require only two out of three MDM components. No change: Code selection for new patients requires three out of three MDM components. Code selection for established patients requires two out of three MDM components.