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Pediatric Office-Based Evaluation and Management Coding: 2021 Revisions

By American Academy of Pediatrics
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Pediatric Office-Based Evaluation and Management Coding: 2021 Revision provides expert guidance on the revised 2021 Current Procedural Technology (CPT ®) office and other outpatient evaluation and management (E/M) codes to help ensure appropriate code selection.

https://shop.aap.org/pediatric-office-based-evaluation-and-management-coding2021-revisions-paperback/

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  1. Page vii
    Introduction
  2. Page 1
    Office and Other Outpatient Evaluation and Management Services
  3. Page 3
    Overview of Office and Other Outpatient Evaluation and Management (E/M) Codes
    1. Page 4
      New Versus Established Patients
    2. Page 6
      E/M Services in Urgent Care Facilities
    3. Page 7
      Visits Not Requiring a Physician’s or Qualified Health Care Professional’s Presence
  4. Page 8
    Office E/M Guidelines
    1. Page 9
      Office E/M Terms and Concepts
  5. Page 12
    Time Guidelines and Application
  6. Page 14
    Medical Decision-making (MDM): Guidelines for Selecting a Level
    1. Page 14
      Number and Complexity of Problems Addressed
    2. Page 19
      Amount and/or Complexity of Data to Be Reviewed and Analyzed
    3. Page 22
      Risk of Complications and/or Morbidity or Mortality of Patient Management
  7. Page 23
    Selection of Level 2 Through 5 Codes
    1. Page 26
      Office E/M Level 2 (99202, 99212)
      1. Page 27
        Time Requirements (in Lieu of MDM)
    2. Page 28
      Office E/M Level 3 (99203, 99213)
      1. Page 28
        Time Requirements (in Lieu of MDM)
    3. Page 29
      Office E/M Level 4 (99204, 99214)
      1. Page 30
        Time Requirements (in Lieu of MDM)
    4. Page 32
      Office E/M Level 5 (99205, 99215)
      1. Page 32
        Time Requirements (in Lieu of MDM)
  8. Page 33
    Prolonged Office E/M Service
    1. Page 33
      Prolonged Service by a Physician or Other Qualified Health Care Professional
    2. Page 36
      Prolonged Clinical Staff Service (99415, 99416)
  9. Page 39
    Split/Shared Office E/M Services
  10. Page 40
    After-hours Services (99050–99058)
    1. Page 41
      Services Provided When the Office Is Normally Closed
    2. Page 41
      Services Provided During Regularly Scheduled Evening, Weekend, or Holiday Hours
    3. Page 42
      Services Provided on an Emergency Basis in the Office
  11. Page 43
    Continuum Models: Asthma, Attention-Deficit/Hyperactivity Disorder, and Otitis Media
  12. Page 48
    Resources
  13. Page 59
    Appendix
  14. Page 51
    Beyond 2020: Office and Other Outpatient Evaluation and Management Coding
  15. Page 53
    The Why and How of Changes to Office and Other Outpatient Evaluation and Management Services
  16. Page 59
    An Overview of Evaluation and Management Changes for 2021
  17. Page 63
    An Overview of Medical Decision-making
  18. Page 71
    An Overview of Time-Based Code Selection
  19. Page 77
    Determining the Number and Complexity of Problems Addressed
  20. Page 81
    Determining the Data Element of Medical Decision-making
  21. Page 85
    Determining Levels of Amount and/or Complexity of Data
  22. Page 89
    Determining the Level of Risk
  23. Page 93
    Examples of Risk in Determination of Overall Medical Decision-making
  24. Page 97
    Evaluation and Management Codes: A Work in Progress
  25. Page 99
    Determining the Level of Medical Decision-making
  26. Page 107
    Level 2 Visits
  27. Page 111
    Versus 2021: When Is 99211 Reported?
  28. Page 115
    Level 3 Visits
  29. Page 119
    Level 4 Visits
  30. Page 125
    Level 5 Visits

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