Evaluation and Management Services in 2021

A new code structure for new and established outpatient E/M services is in effect beginning January 1, 2021. The new structure relies on medical decision-making or time for proper code selection. This activity explores the relationship between medical necessity and medical decision-making in the selection and documentation of outpatient E/M codes. The revised table of medical decision-making will be reviewed along with key definitions important for understanding this new approach to E/M services. It will also address the new guidelines for using time to select an E/M level of service. Clinical examples are included to illustrate the new code structure and the associated documentation requirements.


Learning Objectives
Upon completion of this activity, participants should be able to:

  • Describe the key changes to the Office and Other Outpatient E/M code set for 2021
  • Evaluate how to document and select levels of Office and Other Outpatient E/M Services in 2021
  • Contrast the difference in the criteria used to select Office and Other Outpatient E/M Services in 2021 from other E/M categories of codes
  • Interpret and apply new terminology and definitions to be included in CPT 2021