November 12, 2020

Question:
My coder just told me about the new guidelines for 2021 office visit codes.  She said I no longer have to document a History.  This doesn’t seem right to me.

Answer:
You are wise to ask because that’s not exactly true.  It is correct that the History will no longer be used to select a new patient (9920x) or established patient (9921x) visit code.  However, it is expected that you will document a “medically appropriate” (CPT’s words) history for each encounter.  To learn more about the 2021 E/M coding and documentation changes, please click here.

*This response is based on the best information available as of 11/12/20.