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The current E/M coding guidelines have been in effect for more than 25 years—despite the healthcare industry experiencing momentous change. That all changes in 2021 when medical decision making (MDM) and time become the primary factors for selecting the proper codes.

For urgent care providers, the upcoming coding revisions should be a welcome change. The changes are designed to give providers full credit for the time they spend throughout the entire patient encounter. For example, providers will be able to accurately document the complete approach they took to reach a final diagnosis for a patient—from initial thought processes and research to treatment planning.

Expert tips to help your clinic prepare

As providers and clinic staff prepare for the coding changes in the year ahead, here are four helpful tips to help navigate the new process.

  1. Understand the definitions. One element in the level of code selection is the number and complexity of the problems addressed at an encounter. Make sure your providers are familiar with the definitions for the elements of medical decision making by reviewing this AMA document.
  2. Consider the items you may not document today. There are items that you may not be documenting today that will help with the MDM code evaluation under the new changes. Your providers should understand how to document social determinants of health that may limit ability to be treated, treatments considered, and discussion of management or test interpretation with an appropriate source. Identify any grey areas and decide how to handle and document for all providers in your clinic.
  3. Get in the habit of tracking your time. While not often used in the urgent care setting, total time (face-to-face and non-face-to-face) on the date of the encounter can be used to code the visit. To document, state the total time spent that day and summarize the services performed. Note:
    • Include all time spent on the encounter, even if the patient is no longer in the clinic
    • Exclude time spent by the clinical staff and time spent performing procedures
    • Include time spent by NPPs when both see the patient (only tracking one person per minute)

Since most clinics do not currently track time, determine best practices and a method for how you want your team to manage tracking.

    4. Identify which types of visits should be calculated on time rather than MDM. As you begin to change how you track and document, you will get a sense of when it is most beneficial to bill based on time versus MDM. Each individual encounter should be billed based on what is most appropriate and beneficial for that scenario.

Watch on-demand: Coding in 2021: Properly Using New E/M Coding in the EMR to Regain Revenue >>

Tackle your coding with confidence

On January 1, Experity’s built-in coding engine automatically updates with the new E/M codes to give urgent care clinics increased operational efficiency and accurate, streamlined coding practices. With Experity’s built-in coding engine, the EMR automatically calculates codes based on documentation in the patient’s chart. On the code summary page, providers can review these codes and add their time. The system will then determine which factor to use for billing based on the highest code achieved for the encounter.

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.

Get the essential guide to E/M coding

Watch our on-demand webinar, “An essential guide to E/M coding: Part 1” for an in-depth look at why the E/M codes are changing, how it will improve urgent care, and ways your clinic can prepare.


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