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HIPAA coding changes for E/M office visits

The American Medical Association (AMA) has issued changes to the CPT® evaluation and management (E/M) office visit code structure, effective Jan. 1, 2021. The changes affect both payers and providers.

If you are a contracted Magellan provider who is qualified to provide E/M office visits (CPT codes 99202-99205, 99211-99215), you will receive an amendment to your Magellan Agreement in the coming weeks reflecting the changes. In the meantime, check out answers to frequently asked questions (PDF).

Key points for Magellan providers

  • Changes impact psychiatrists and qualified health practitioners who perform E/M office visit services.
  • Important elements of the E/M office visit changes include:
    • Eliminating history and physical exam as an element for code selection.
    • Allowing physicians to choose whether documentation is based on medical decision-making (MDM) or using total time, which includes non-face-to-face work done on the day of the office visit.
    • Changing MDM criteria to focus on tasks that affect the management of a patient’s condition instead of merely cataloging tasks. MDM criteria will include new definitions.
  • CPT code 99201 was deleted, effective Jan. 1, 2021.
  • Except for 99211, time alone may be used to report the appropriate code level for the E/M office visit services. Codes 99202-99205 and 99212-99215 now have defined time ranges (e.g., 99215 Office Visit, established patient, 40-54 minutes).
  • Providers are to use a new add-on code, 99417, when reporting 15-minute increments of prolonged services with E/M office visit level 5 codes 99205 and 99215 for non-Medicare Advantage members.
  • Since CMS does not recognize 99417 for Medicare, providers must use G2212 when reporting 15-minute increments of prolonged services for 99205 and 99215 for Medicare Advantage members.
  • Note: CMS defines total time as the sum of all time, including prolonged services time, that the reporting practitioner spends on the date of service.
  • Magellan providers billing prolonged time for Magellan members should follow CMS’ guidelines for reporting prolonged time using total time in the FAQ. Magellan providers should only bill the new prolonged services codes when the total time of 99205 or 99215 has been exceeded by the full 15 minutes.

Learn more

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

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Welcome to Provider Focus, our award-winning e-newsletter for network providers! Here you’ll find articles and information to keep you up-to-date on news and topics relevant to serving Magellan members, including a section for regional- and plan-specific news. Check back as a new issue is released each quarter.

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