Coding for office visit evaluation and management (E/M) in 2021 and beyond: Frequently asked questions (FAQs)
The following scenarios of dermatology encounters have been developed by the American Academy of Dermatology Association (AAD/A) coding team. The 2021 office and other outpatient evaluation and management (E/M) coding guidelines were used to determine the appropriate E/M level of service. Dermatology practices are encouraged to use these examples to get familiar with and understand how to apply the new coding guidelines.
Scenarios for new patients
Q1. A 50-year old new male patient presents for skin cancer screening. He has no other concerns. No data is reviewed. A total body skin exam is performed. On exam, he has a few scattered nevi and seborrheic keratoses, but nothing remarkable.
No treatments are recommended, but he is counselled on the importance of using sunscreen. He will follow-up as needed.
Using medical decision making (MDM), what is the appropriate E/M code for this encounter?
A1. In this encounter, the patient presents two self-limited minor problems: (benign nevi, seborrheic keratoses) which considered low under number and complexity of problems addressed. There was no data to be reviewed which meets the criteria of minimal or none under amount and/or complexity of data to be reviewed and analyzed. The risk of complications and/or morbidity or mortality of patient management includes recommending use of sunscreen qualifying this as a minimal level.
Although the FDA includes broad-spectrum sunscreen with SPF 15 or higher in its list of over-the-counter medications, it is important to document this distinction in the event of a post-claim audit to support the level of service reported.
Appropriate code
This encounter meets the requirements for a Straightforward level of MDM:
99202
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
Q2. A new patient is referred to you and presents with nodulocystic acne that has been present for the past six months. You spend five minutes reviewing outside medical records and the patient’s intake history prior to the face-to-face encounter with the patient that lasts 15 minutes. After the personal encounter, you spend an additional five minutes ordering labs and dictating a referral note.
Your staff take 10 minutes reviewing the iPLEDGE program with the patient and entering the patient’s data into the iPLEDGE website. You document the total time spent as 35 minutes in pre-, intra-, and post-service time.
What is the appropriate code for this encounter based on time?
A2. Although the medical record documentation indicates that the total time spent between the physician and staff during the pre-, intra- and post-service total of 35 minutes, per the 2021 E/M guidelines only the time spent by the physician/non-physician clinician (NCP) is actually counted toward the appropriate office E/M service code choice, not ancillary staff time.
As such, the total physician time for this encounter is 25 minutes (5 minutes pre-service, 15 minutes intra-service, and 5 minutes post-service time).
Appropriate code
This encounter meets the requirements for a Straightforward level of service based on time:
99202
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
Q3. Early in the morning, you spend 10 minutes reviewing a pathology report, including microscope slides and a referral letter along with patient records for a new patient scheduled to see you in afternoon.
Later in the day — but immediately prior to seeing the patient in person — you review the patient chart data for three minutes and then spend 20 minutes with the patient doing a complete skin examination, explaining the nature of the patient’s melanoma, and reviewing the recommended treatment plan.
Your staff schedule the patient for a therapeutic wide excision later in the week and you take two minutes dictating a note to the referring physician.
What is the correct E/M code to be reported based on time?
If based on time, what is the appropriate code for this encounter?
A3. Although the 10 minutes of time spent reviewing data and microscope slides did not immediately precede the face-to-face patient interaction, these minutes are still counted toward the total physician/NCP time, as time is determined by the total time on the day of the encounter.
Appropriate code
The total time of 32 minutes which includes the 10 minutes of data review, 20 minutes with the patient, and two minutes entering data is reported with:
99203
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter .
Q4. A 35-year-old new female patient presents to the office for treatment of persistent inflammatory acne, predominately on her lower cheeks and jawline.
She has previously taken courses of oral antibiotics without long-term improvement and is on a combined oral contraceptive pill and has no plans for future pregnancies. She is otherwise healthy and only takes a daily multivitamin.
After taking a relevant history and performing an appropriate physical exam, you make the decision to initiate treatment with a spironolactone.
Using MDM as the coding criteria, what is the appropriate level of service for this encounter?
A4. In this encounter, the MDM is considered “moderate” because the patient presents with one chronic illness that is poorly controlled — acne vulgaris.
According to CPT, a chronic illness that is acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care is considered a problem at the Moderate level.
The risk of patient management has a moderate risk of morbidity due to prescription drug management. There is no additional data (minimal complexity) for the dermatologist to review.
Appropriate code
This encounter meets the requirements for a Moderate level of MDM:
99204
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
Q5. A 72-year-old man referred for Mohs surgical excision of a nasal basal cell carcinoma (BCC) comes in for an evaluation and consultation prior to scheduling for Mohs surgery. Spot at nasal site has “come and gone” for a year but in the past 2 months seems to be growing and bleeding recurrently.
You review the referral letter and evaluate the histopathology report. A medically appropriate history and examination of the nasal site is performed. You then discuss Mohs surgery and reconstruction options for this otherwise healthy male. The patient schedules for Mohs surgery and flap reconstruction the following week.
Based on MDM, what is the appropriate E/M code for this encounter?
A5. BCC is considered a single chronic illness that is not stable as it has progressed, growing in size and increased bleeding. The problem addressed is considered moderate and the encounter includes a review of external notes and test results which qualifies as low level under data to be reviewed. An elective major surgery with no identified risk factors is scheduled as the treatment option which appropriately supports a moderate level of risk of complications and morbidity.
Appropriate code
This encounter meets the requirements for a Moderate level of MDM:
99204
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
Scenarios for established patients
Q6. An established patient with a history of skin cancer presents for routine screening.
She has no concerns except for some hyperpigmentation on the forehead and some spots on the trunk that turns out to be seborrheic keratosis. No data is reviewed. A total body skin exam reveals no concerning findings. Photoprotection, including broad-spectrum SPF-15 or higher sunscreen, is suggested.
What is the correct code for this encounter based on MDM?
A6. This patient presents with two or more self-limited minor problems, hyperpigmentation and seborrheic keratosis, which is considered low under number and complexity of problems addressed. There was no data to be reviewed which meets the criteria of minimal or none under amount and/or complexity of data to be reviewed and analyzed. The risk of complications and/or morbidity or mortality of patient management includes recommending use of broad-spectrum sunscreen qualifying this as low-risk level.
Appropriate code
This encounter meets the requirements for a low level of MDM:
99213
Office or other outpatient visit for the of an established patient, which requires a medically appropriate history and/or examination and straightforward.
Q7. An established patient presents for follow-up of a clearing patch of localized contact dermatitis.
You spend 15 minutes discussing the problem with the patient, ordering medications, and documenting in the patient medical record.
Using time for code selection, what is the appropriate code for this encounter?
A7. When using time for code selection, only time spent by the dermatologist/NCP caring for the patient is counted toward the code selection.
In this encounter, the dermatologist spent 15 minutes discussing the problem, ordering medication and document in the medical record on the date of the encounter.
Appropriate code
This encounter meets the requirements for a Straightforward level for time-based code:
99212
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
Q8. A 56-year-old established male patient presents to the office after his wife noticed a new dark brown spot on his back. He says she told him to “schedule an appointment and have it checked”. The spot is asymptomatic.
You perform a medically appropriate physical examination which reveals a dark brown flat, stippled surface 1 cm “stuck on” papule typical of a seborrheic keratosis. Patient has no history of atypical nevi or skin cancer. No treatment is recommended.
Using MDM, what is the appropriate code for this encounter?
A8. In this scenario the patient presents with one self–limited or minor problem (atypical nevi) which is considered minimal under the element for number and complexity of problems addressed. There is minimal or no data to be reviewed or analyzed, and since there is no treatment recommended, the risk of complications and/or morbidity or mortality of patient management is minimal or none.
Appropriate code
This encounter meets the requirements for a Straightforward level of MDM:
99212
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.
Q9. A 47-year-old established male patient presents with itchy, red, and cracking hands. The patient works in construction as a concrete mixer. He states that sometimes, his hands blister and bleed. They improve when he goes on vacation. You determine that the patient has irritant contact dermatitis due to continuous cement exposure and prescribe a topical corticosteroid. Over the counter (OTC) emollients are recommended. Patient education on benefits of using personal protective equipment (PPE) is also provided. Using MDM, what is the appropriate E/M level service code for an established patient encounter for this patient based on the new E/M coding guidelines? Keep in mind that the documentation of the encounter must meet or exceed two out of the three MDM elements for the selected E/M code.
A9. In this encounter, the patient presents with one acute, uncomplicated illness, irritant contact dermatitis, for which the dermatologist prescribes medication and provides education on importance of PPE. The coding and procedural terminology (CPT) defines acute, uncomplicated illness or injury as a recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. As such, this problem meets the low level for complexity and number of problems addressed. There was no data to be reviewed which supports minimal complexity of data to be reviewed and analyzed level, while the treatment course has a moderate risk due to the prescribed topical drug management.
Appropriate code
This encounter meets requirements for a low-level MDM complexity:
99213
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
Q10. Using MDM, what is the appropriate E/M code for an established patient encounter for a 16-year old male with previously stable acne who today presents with exacerbation of severe nodulocystic acne requiring care coordination and initiation of isotretinoin therapy?
You provide patient education, informed consent is obtained, and laboratory testing is ordered prior to initiating treatment.
A10. Based on the new E/M coding guidelines, the encounter must meet or exceed two out of the three elements for the selected E/M code.
In this encounter, the patient presents with one chronic illness with exacerbation for which the dermatologist prescribes medication, orders and will review laboratory testing.
The chronic illness with exacerbation meets the moderate level for number of problems addressed. The laboratory test is ordered and will be reviewed by the dermatologist which supports the requirement for limited complexity of data to be reviewed and analyzed, while the treatment course has a moderate risk of morbidity due to prescription drug management.
Appropriate code
This encounter meets the requirements for a moderate level of MDM complexity:
99214
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
Q11. An 18-year-old man presents for evaluation of a wound on his right forearm and an acute onset of malaise. He was previously seen for management of atopic dermatitis in the practice two years ago, which is currently well-controlled with the use of topical corticosteroids as needed for flare-ups.
He states that he was attempting to pet his girlfriend’s cat, who (the cat) then became agitated and bit him.
His physical exam is notable for a 3mm ulceration consistent with a puncture wound with surrounding ill-defined erythema, edema, and warmth. There is mild tenderness to palpation but no fluctuance. He denies fevers or chills currently.
Amoxicillin-clavulanic acid is recommended and ordered through the pharmacy to treat the feline bite.
Using MDM, what is the appropriate E/M code?
A11. In this case the encounter meets the criteria for a moderate level of MDM because you are managing one acute illness with systemic symptoms (moderate complexity). There is minimal or no data to be review or analyzed and there is a moderate risk of morbidity of patient management, namely the systemic antibiotic.
Appropriate code
As two out of the three elements for a moderate level of MDM have been met, this would be classified as a moderate MDM level encounter. Furthermore, as this patient has been previously seen, the correct code in this scenario would be:
99214
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
Review the E/M Office Visit Medical Decision Making Table (PDF download) to determine the appropriate level of E/M service for various encounters. And be sure to visit the Academy’s Coding Resource Center for additional coding guidance and resources.
