Documentation Guidelines for Evaluation and Management Services

2021 E/M Guidelines

Effective January 1, 2021 Highmark is aligning with the E/M coding changes for Office and Outpatient Services to allow clinicians to choose the E/M visit level based on either medical decision making or time.  

These guidelines are specific to procedure codes 99202-99215. All other categories of E/M services should be reported using the CMS 1995 and/or 1997 Documentation Guidelines.

What’s New in 2021

Prior to 2021 E/M Guidelines

Below you will find the Documentation Guidelines that were effective prior to the 2021 Changes and those that are still in effect for Categories other than Outpatient and Office E/M codes (99202-99215)

Last updated on 10/22/2021

 

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