2021 Evaluation and Management Codes: Is a History and Exam Required?

Question:

After a recent audit and review with my physicians, they are telling me that they do not need to document a history and/or exam any more for the new and established patients. That is not my understanding.

Answer:

You are wise to ask because that’s not exactly true; we hear it not infrequently. It is correct that the History or Exam will no longer be used to select a new patient (9920x) or established patient (9921x) visit code. However, it is expected that the physician/provider will document a “medically appropriate” (per CPT™) history and exam for each encounter.

In Orthopaedics, we find the History section to provide important information that assists with the Data Element sections in the MDM table. Items such as the location, duration of the problem, past treatments such as injections, documentation that external X-Rays were brought with the patient are helpful in determining the level of risk in addition to the remainder of the note.