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Big changes coming in E/M coding and payment

| August 31, 2020

Big changes coming in E/M coding and payment

Beginning January 1, 2021, there will be new rules for reporting and documenting outpatient evaluation and management (E/M) services. These changes, which are the culmination of a multi-year process led by the American Medical Association (AMA) (and in which the Advocacy Council actively participated), will impact how you document and report the care you provide. The changes are designed to relieve some of the administrative burden associated with E/M coding and documentation by making code selection simpler and more intuitive. These changes are summarized below along with resources to find out more.

FINAL coding/documentation changes approved for 2021

Coding can be based on medical decision making or time

Physicians will be able to choose whether to code based on time or medical decision making (MDM), even when counseling and coordination of care do not predominate. Time will be based on specified minimum times and not typical times and will include physician or qualified health care professional (QHP) time on the date of service. Total time can include both face-to-face and non-face-to-face time spent by the physician or QHP but it does not include activities performed by clinical staff.

The table below indicates the range of time for the outpatient E/M codes when coding is based on time.

CPT Outpatient E/M CodeTime Range When Coding Based on Time
99201Deleted
9920215-29 minutes
9920330-44 minutes
9920445-59 minutes
9920560-74 minutes
99211N/A
9921210-19 minutes
9921320-29 minutes
9921430-39 minutes
9921540-45 minutes

 

Where coding is based on MDM, the focus is on the number and complexity of problems addressed, data to be reviewed, and risk of complications and/or morbidity/mortality.

More detailed information on code selection criteria can be found on the AMA website.

History and exam no longer basis for code selection

Medicare is eliminating the clinically outdated requirement for review and examination of a certain number of body systems. History and exams will count only when performed and need only be medically appropriate for the presenting problem.

What should you do to prepare for these changes?

  • Schedule education and preparation time for your clinical and billing teams.
  • Update practice protocols to be consistent with new guidelines.
  • Check to be sure your electronic health record (EHR) vendor has a schedule for implementing the new E/M office visit changes.
  • Pay attention to medical malpractice liability. Even though E/M documentation requirements will be more flexible, documentation is the best way to protect against malpractice liability.

The AMA has a number of resources on its website, including a series of learning modules on 2021 E&M Coding.

The Advocacy Council will continue to monitor and report on all coding changes for 2021. The Advocacy Council – we have you covered!

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