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The current Centers for Medicare and Medicaid Services (CMS) coding guidelines date back to 1995. For the last 25 years, providers have been frustrated by the complexity of documentation requirements and “documenting for the sake of documenting.”

As part of the Final Rule in 2019, CMS proposed to simplify guidelines moving forward. In response, the American Medical Association (AMA) asked for opportunity to address the guidelines at a provider level with the goal to:

  • Decrease the administrative burden of documentation and coding
  • Decrease the need for audits
  • Decrease unnecessary documentation in the medical record
  • Ensure payment for E/M is resource-based with no direct goal for payment redistributions between specialties

The new coding guidelines will go into effect on January 1 and will affect the way providers document. It’s important to understand what to expect, so we’ve put together this brief overview of what is changing. Read the full AMA guidelines here.

Summary of 2021 E/M Coding Changes

The biggest change providers will see with the new guidelines is that E/M documentation will focus on medical decision making (MDM) or time. Starting January 1, history and exam elements should only be captured when clinically appropriate. Providers can use whichever method—MDM or time—that is most beneficial for each visit.

Criteria of MDM

The AMA spent a lot of time putting together the new guidelines from the doctor’s perspective, using the table of risk but simplifying to match what is actually done in an office setting. In order to define items that had previously been in a gray area, the AMA wanted to assure the new guidelines:

  • Created sufficient detail in CPT code set to reduce variation between contractors/payers
  • Attempted to align criteria with clinically intuitive concepts
  • Used existing CMS and contractor tools to reduce disruption in coding patterns
  • Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”)

While similar, this is not the MDM calculation we have today. All code descriptors state a “medically appropriate” history and/or examination and MDM. The amount of history and exam performed and documented is now up to the provider and will not be a consideration in code selection. Code selection will now reflect true practice activities and be simplified to match what is done in an office setting.

Elements of MDM

The level of MDM is based on two out of three elements:

  • Number and complexity of problems addressed
    • A problem is addressed when it is evaluated or treated at the encounter by the physician or other qualified professional reporting the service
  • Amount and/or complexity of data to be reviewed and analyzed
    • This is the biggest change and emphasizes clinically important activities and accounts for quantity of documents ordered/reviewed.
    • Data is divided into three categories:
      • Tests, documents, orders, or independent historian(s)
      • Independent interpretation of tests
      • Discussion of management of test interpretation with external physician/other QHP/appropriate source
    • Risk of complications and/or morbidity or mortality of patient management
      • Decisions involved with the patient’s problem(s) or treatment(s) including possible management options selected and considered, as well as risks associated with social determinants of health

Criteria of Time

While tracking time is not often used in the urgent care setting, it’s important to understand how to use time to code a visit. With the new rules, total time is considered face-to-face and non-face-to-face on the date of the encounter by the “reporting” practitioner. To document, state the total time spent that day and summarize the services performed.

It’s important to note that the criteria for time:

  • Does not require the patient to be in the office
  • Excludes time spent by the clinical staff
  • Excludes time spent performing procedures
  • Includes time spent by NPPs when both practitioners see a patient, but can only count one person per minute

Additional Resources

  • Code and Guideline Changes: The AMA is the definitive source for information regarding the 2021 E/M changes. Additional information including definitions and an MDM decision-making grid can be found here.
  • An Essential Guide to E/M Coding webinar series: Experity’s recent coding webinar provides a deeper look into the information above. Access the recording here.

Disclaimer:The discussions and materials, regarding the history, application, future use and expected evolution of evaluation and management codes (“e/m codes” or “e/m coding”) set forth in this resource are statements of opinion and/or projections based upon experience, research and information available as of the date of the publication. Nothing contained herein shall be interpreted as legal advice nor any guarantee of results.

Phyllis Dobberstein

Phyllis Dobberstein,
Manager, Compliance & Security

Born and raised in suburban Minneapolis, Phyllis has spent her professional career in the world of billing and compliance—guiding teams around the obstacles and over the hurdles that interfere with full compliance. She believes that education and communication are key to creating and nurturing a culture of compliance. “Everyone wants to do the right thing. My role is to make sure everyone knows the right thing—both within the company and our clients.” As the company’s Compliance and Privacy Officer, Phyllis supports the company’s RCM efforts by providing education, helping to develop best practices and standards policies, and ensuring compliant documentation, not only for Experity, but for all of our customers.
View Phyllis’s posts

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