CHICAGO— The first major overhaul in more than 25 years to the codes and guidelines for office and other outpatient evaluation and management (E/M) services was included in today’s release of the 2021 Current Procedural Terminology (CPT®) code set published by the American Medical Association (AMA).

These foundational modifications were designed to make E/M office visit coding and documentation simpler and more flexible, freeing physicians and care teams from clinically irrelevant administrative burdens that led to time-wasting note bloat and box checking. The changes to CPT codes ranging from 99201-99215 are proposed for adoption by the Centers for Medicare and Medicaid Services on Jan. 1, 2021.

The E/M office visit modifications include:

  • Eliminating history and physical exam as elements for code selection.
  • Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time.
  • Promoting payer consistency with more detail added to CPT code descriptors and guidelines.