Journal of Dermatology for Physician Assistants

The official journal of the Society of Dermatology Physician Assistants

Adjusting to the New 2021 Evaluation & Management Documentation Guidelines

By Jaci J. Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPCI

Welcome to Compliance Corner, a new department dedicated to providing information and tools to help keep your healthcare documentation for coding and billing compliant. This new resource aims to help you navigate recent changes to Current Procedural Terminology® (CPT®) Evaluation and Management (E/M) guidelines for office visits, which became effective January 1, 2021. Written by the American Medical Association (AMA), these guidelines contain new methodology and new definitions, both of which affect the way you as providers document the account of the patient visit.

As is often the case with significant change, attempts to comprehend and adapt to new guidelines has set off a chain reaction of follow-up questions. Here, we will provide clinical examples to assist in the explanation of these new requirements to support the different levels of service of CPT office visit codes. We will also feature YOUR questions on all compliance-related topics along with answers that walk you through the rationale for each response. Compliance Corner will contain a selection Q&As from you, the readership. If you have a scenario or question, we encourage you to send it to coding@ for review.

Let’s dig right into our inaugural installment, where we tackle the BIG questions:

1) What do these new CPT® E/M guidelines mean?
2) What are the potential confusing or gray areas? And
3) What steps do you need to take to ensure compliance?

Discussing the new guidelines is a great opportunity to review history and reflect on what was learned prior to the 2021 change. The CPT system developed by the AMA remains the most widely accepted nomenclature to report for health claims processing. The descriptive terminology and associated code numbers were intended to “speak” to providers, thus standardizing communication. Your documentation needs to properly communicate in this language all details supporting your medical decision-making process from beginning to end. This includes description of the presenting “problem,” evaluation, diagnosis, treatment or “problems addressed,” along with any additional services provided, such as in-office procedures.

The following cheat sheets highlighting the Do’s and Don’ts of documentation will assist you in working through each step of the process.

Your Burning E/M Coding Questions…ANSWERED

Question: With these new E/M changes for 2021, I am not seeing anything about “consult” level of billing changes. My employer does want us to bill for “consults” when appropriate and to payers that still allow them, so is there anything new I should know about billing out “consults?”

Answer: These new guidelines do not apply to consult codes (99241 – 99245 or 99251 – 99252). Those codes will be audited using the 1995 or 1997 guidelines. The guidelines per CPT remain the same. The documentation for a consult must contain the three R’s of consults.

1. Document who Requested the consult
2. Document the Reason for the consult
3. Document that the information requested was Returned to the requesting party.

Question: Is the new coding like the old coding in that if we freeze actinic keratoses (AKs) then we do not also link the diagnosis of AKs to the office visit E/M code (since it is linked to the 17000 and 17003 codes)?

Answer: If the AKs were addressed, which I am sure they were, then yes, you should link those to the visit code also. The rules of the modifier 25 indicate that you do not have to have separate diagnosis codes. However, if your business office insists, then follow that internal policy. I am stating the coding rule here and it is acceptable to use that diagnosis with the office visit CPT code.

Question: If we do a full-body skin exam and have two or more chronic stable conditions (e.g., unchanged nevi and chronic seborrheic keratoses) and we freeze two AKs on the arm and give a prescription for efudex cream for AKs on the nose, is this 99214 since we had two or more chronic stable conditions and have prescription drug management? Or can we not bill for both the medical decision making for the prescription and for the procedures 17000/17003 since they are both for the same diagnosis?

Answer: Without seeing any documentation, I am basing this response solely on the scenario provided. The two stable chronic and the prescription would equate to a 99214.

Question: If we do skin check and have two chronic stable conditions plus do a biopsy on an “undiagnosed new problem with uncertain prognosis,” is this a 99214 since we made decision to do minor surgery (biopsy) with identified risks? Or, since the D48.5 is attached to 11102 code, can we not use it for our E/M code, making it a 99213?

Answer: Consider the definition provided by the AMA:

Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.

If your documentation will support this definition (an auditor is not going to do it for you), then the problem addressed will equal moderate (99214). If your documentation does not meet this criteria, then the moderate complexity can be reached by the documentation of two stable chronic conditions.

Now, let’s consider the definition of risk for minor surgery from the AMA:

Surgery–Minor or Major: The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification.

If your documentation can meet this definition, than the Risk portion would also meet the criteria for Moderate and 99214.
Meet both of those documentation requirements and yes, you have a 99214. The diagnosis D48.5 should be linked to the office visit in addition to any other conditions that were addressed.

Jaci J. Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPCI, has been working in the field of medical coding and auditing for over 30 years. She has been a Certified Professional Coder (CPC) since 1994, attained her Certified Outpatient Coder (COC) for facility-based coding in 2005, and is a Certified Professional Medical Auditor specializing in Evaluation and Management (E/M) Coding. She has expertise in coding for family practice, urgent care, obstetrics and gynecology, general surgery, and Medicare’s Teaching Physician Guidelines, with a particular emphasis on E/M guideline compliance. She has served on the American Academy of Professional Coders (AAPC) National Advisory Board and is past president of AAPC’s Richmond and Charlottesville, Virginia, local chapters. Kipreos is president of Practice Integrity, LLC, where she manages a national client list and provides compliance monitoring for provider documentation. She currently resides in San Diego, California.

Disclosures: The author has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article.

Address for Correspondence: If you have a question or comment, we encourage you to send it to

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