E/M coding and documentation changes for 2021, explained

The Medical Group Management Association’s most recent MGMA Stat poll asked healthcare leaders, “Is your practice prepared for E/M changes in 2021?” The majority (53%) responded “no,” while 47% said “yes.” 

The poll was conducted Oct. 6, 2020, with 552 applicable responses.

Many changes published by the American Medical Association CPT Editorial Panel have largely been adopted by the Centers for Medicare & Medicaid Services (CMS):

• 99201 will be deleted due to low utilization.
• Time-based coding will be based on total time the qualified healthcare provider (QHP) utilized. 
• Documentation of time-based coding will be determined by face-to-face and non-face-to-face activities:
  • Preparing to see the patient (e.g., review of tests, review of previous medical record documentation)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other health care professionals (when not separately reported)
  • Documenting clinical information in the electronic or other health record
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • Care coordination (not separately reported)
• The QHP must document total time utilized (e.g., “I spent a total of 15 minutes reviewing patient’s labwork, discussing referral option to specialist, setting up X-rays and discussing diagnoses with patient and spouse).
  • In this example, new patient office visit could be coded at 99202 or established patient office visit as 99212.

Table 1. Time requirements for new patient and established patient codes 99202-99205, 99211-99215

Another component of E/M that will reflect significant changes will be medical decision making (MDM), in which three elements help determine code selection:

1. Number and complexity of problems addressed
2. Amount and/or complexity of data reviewed and analyzed
3. Risk of complications and/or morbidity or mortality

Data will be divided into three categories:

• Category 1: tests, documents, orders, and review of prior external note(s) from each unique source or independent historian(s) — each unique test, order, or document is counted to meet a threshold number
• Category 2: independent interpretation of tests not reported separately
• Category 3: discussion of management or test interpretation with external physician/other qualified health care provider/appropriate source (not reported separately)

The new MDM table for leveling and code selection is available at bit.ly/3iqiQ0q.

The changes to E/M services have goals in alignment with various resolutions:

Table 2. Goals and resolutions for E/M updates

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Additional resources:

• "Preparing your practice for 2021 E/M changes" (MGMA Connection)
• 2021 Physician E/M Fee Schedule Analyzer Tool (Non-facility) [MGMA member tool]
• AMA code and guideline changes for outpatient E/M visits (PDF)