CMS Reviewing Evaluation and Management Service Selections in 2021
In 2021, the Centers for Medicare and Medicaid Services (CMS) will use the medical record documentation to determine the medical necessity of an Evaluation and Management (E/M) Office and Outpatient visit (99202-99215). Reviewers will be looking at the accuracy of the documentation regarding the time spent, if the evaluation and management service is selected based on time. Documentation should include either a start/stop time or a statement regarding total time. Time now includes both face-to-face and non-face-to-face activities as outlined in the American Medical Association CPT E/M Guidelines. View the CMS Fact Sheet.