The key components of an Evaluation and Management (E/M) service have changed as of January 1, 2021 for Office and other Outpatient Services only. History and exam are no longer used to select the level of code for an office and other outpatient visit. Selection of a code level is based on either the newly defined level of medical decision making (MDM), or total time personally spent by the reporting practitioner on the day of the visit. Proper medical documentation will tell a story of the patient's visit by recording pertinent facts, findings and observations.

Changes for 2021

The new E/M codes for office visits eliminate the history and physical key elements for code selection, and the new E/M guidelines state that records should document a medically appropriate history and/or examination. The level of code chosen will be based on either MDM or time. All other E/M codes (Inpatient, Observation, Emergency Department etc.) remain unchanged for 2021.

Medical Decision-Making Changes

The levels of MDM for each E/M service are based on three categories.

  1. The number and complexity of problems(s) that are addressed during the encounter. 
  2. The amount and/or complexity of data to be reviewed and analyzed. Please see the AMA resources for the new table of risk for MDM. 
  3. The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit, associated with the patient's problem(s). There are still four types of medical decision making recognized: straight-forward, low, moderate and high.

Refer to your CPT book to determine the correct code needed and what components are needed for MDM.

Picking Service Level Based on Time

Time alone may be used to select the appropriate code level for the office or other outpatient E/M service codes (99202-99215). New for 2021 is the use of total time on the date of the encounter. Time for the office services is the total time on the date of the encounter, to include both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional on the day of the encounter. The professional time includes the following activities:

  • Preparing to see the patient (eg, review of tests)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other health care professionals (when not separately reported)
  • Documenting clinical information in the electronic or other health record
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • Care coordination (not separately reported)


CPT codes for office, or other outpatient:

New patient E/M codes (99202–99205 [99201 has been deleted]) require the following components: A medically appropriate history and/or examination and either:

  • A straightforward MDM (99202) (time 15-29 mins.),
  • Low level MDM (99203) (time 30-44 mins.),
  • Moderate level (99204) (time 45-59 mins.) or a
  • High level MDM (99205) (time 60-74 mins.)

Established office or other outpatient visits require the following components:

  • A minimal presenting problem that may not require the presence of a physician or other qualified health care professional (99211),
  • A medical appropriate history and/or examination and either a straightforward MDM (99212) (time 10-19 mins.),
  • Low level MDM (99213) (time 20-29 mins.),
  • Moderate level (99214) (time 30-39 mins.) or a
  • High level MDM (99215) (time 40-54 mins.)

Documentation Tips

In addition to the components of an E/M service, there are several principles of medical documentation that must be considered:

  • The medical record should be complete and legible
  • The documentation for each patient encounter should include:
  • If not documented, the rationale for ordering diagnostic and other ancillary services should be able to be inferred easily
  • Past and present diagnoses should be accessible to the treating and/or consulting physician
  • Appropriate health risk factors should be identified
  • The patient's progress, response to treatment, changes in treatment and revision of diagnosis should be documented
  • The CPT and ICD-9-CM codes reported on the claim form or billing statement should be supported by the documentation in the medical record

Payers will request medical records to compare billing (your choice of CPT and ICD-10 codes) with documentation. They will check for site of service errors, the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided and an accurate reporting of services provided.

Each office note must tell a complete story (also referred to as a "stand alone" note). If auditors want to review an office note from Aug. 18, 2019, they will not look at a previous visit (or any other visit) unless that visit is referenced in the August 18, 2019 note.

Additional Information and Resources