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CPT code 99211 (established patient, level 1) will remain as a reportable service.
The chief complaint will continue to be required for each E/M visit. The history and exam have been eliminated for code selection, and only need to be performed and documented for the visit when medically necessary and clinically appropriate.
Review of systems should be medically necessary. It may be considered necessary to obtain a complete ROS when a patient presents as an initial new patient. It may not be considered medically necessary to repeat that complete review on every follow up.
New Patient Visits 2021 CPT CodeMedical Decision MakingTotal Time99202Straightforward15\u20132999203Low30\u20134499204Moderate45\u20135999205High60\u2013741 more row
In 2021, history and exam will no longer be used to select an E&M service, but still must be performed in order to report CPT ® codes 99202-99215. In 2021, E&M code selection will be based on either 1) The level of medical decision making (MDM) OR 2) The time performing the service on the day of the encounter.
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E/M services represent a category of Current Procedural Terminology (CPT) codes used for billing purposes. Most patient visits require an E/M code. There are different levels of E/M codes, which are determined by the complexity of a patient visit and documentation requirements.
Since CPT code 99417 and G2212 were created to describe a 15-minute prolonged office or other evaluation and management services (with OR without direct patient contact), CPT codes 99354 and 99355 can no longer be reported with CPT codes 99202-99215 in 2021.
Medical Coding Tools - ICD-9-CM, ICD-10-CM, CPT®, HCPCS, ABC, DRG, APC.
The American Medical Association (AMA) CPT® panel changed the definitions, and CMS is in agreement with these. The changes below relate only to new and established patient visits in 2021, codes 99202\u201499215. These changes are in the 2021 CPT book.
Major E/M changes for 2021 include: Eliminating history and physical exam as elements for code selection. Allowing physicians to choose whether their documentation is based on medical decision making (MDM) or total time on date of service.

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