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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
    1. 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
    2. Page 8
      Office E/M Guidelines
      1. Page 9
        Office E/M Terms and Concepts
    3. Page 12
      Time Guidelines and Application
    4. 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
    5. 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)
    6. 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)
    7. Page 39
      Split/Shared Office E/M Services
    8. 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
    9. Page 43
      Continuum Models: Asthma, Attention-Deficit/Hyperactivity Disorder, and Otitis Media
    10. Page 48
      Resources
  3. Page 59
    Appendix
  4. Page 51
    Beyond 2020: Office and Other Outpatient Evaluation and Management Coding
  5. Page 53
    The Why and How of Changes to Office and Other Outpatient Evaluation and Management Services
  6. Page 59
    An Overview of Evaluation and Management Changes for 2021
  7. Page 63
    An Overview of Medical Decision-making
  8. Page 71
    An Overview of Time-Based Code Selection
  9. Page 77
    Determining the Number and Complexity of Problems Addressed
  10. Page 81
    Determining the Data Element of Medical Decision-making
  11. Page 85
    Determining Levels of Amount and/or Complexity of Data
  12. Page 89
    Determining the Level of Risk
  13. Page 93
    Examples of Risk in Determination of Overall Medical Decision-making
  14. Page 97
    Evaluation and Management Codes: A Work in Progress
  15. Page 99
    Determining the Level of Medical Decision-making
  16. Page 107
    Level 2 Visits
  17. Page 111
    2020 Versus 2021: When Is 99211 Reported?
  18. Page 115
    Level 3 Visits
  19. Page 119
    Level 4 Visits
  20. Page 125
    Level 5 Visits

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