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1:55-2:45 p.m.

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Preparing for Changes in Evaluation and Management Coding for Office Encounters

Presenters at this session will review major changes to the requirements for reporting office-based evaluation and management codes (CPT® codes 99202-99215) that went into effect during the pandemic for telehealth visits, and are scheduled to go into effect for all office visits on January 1, 2021.

CMS and the American Medical Association have approved landmark changes that will (for the most part) simplify the documentation and other requirements for reporting office-based visit codes. The traditional history and physical components of documentation will no longer be used to determine the level of E/M service. The E/M code submitted will be based on either the amount of time spent providing care to the patient or the level of complexity or medical decision making (MDM).

Presenters will also explore the modified requirements to time-based reporting in detail and present clinical examples. Finally, they will review significant modifications made to the requirements for the determination of the level of complexity of MDM starting in 2021.

Learner Outcomes

After completing this session, participants will be able to:
• Understand the scope of the Medicare telehealth waivers that address evaluation and management (E/M) office CPT® codes 99202-99215 and telephone E/M service codes 99441-99443.
• Understand the scope of the 2021 changes to E/M office CPT® codes 99202-99215.
• Be aware of the major changes to documentation requirements, including the removal of the history and physical as part of the level of service determination.
• Understand how the E/M level of service will be determined starting in 2021.
• Have knowledge of the significant changes to requirements when using time to determine the E/M level of service.
• Understand how to determine the E/M level of service based on the revised complexity of medical decision making requirements.
• Be aware of how these changes to documentation requirements may impact clinical care, auditing, clinical documentation integrity, and risk adjustment.


Michael Stearns, MD, CPC, CRC, CFPC
Apollo HIT, LLC Austin, TX
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