E/M Documentation Revisions for 2021 are around the corner

AMA is on track to revise E/M codes and set new documentation guidelines. What was considered to only target the Office and Other Outpatient visits, has now been expanded to impact the entire E/M section of CPT®.

The AMA’s CPT® Editorial Panel approved many changes to the Evaluation and Management documentation and coding guidelines. If finalized, the changes will shift the way medical practices select codes for both office and facility visits as soon as January 2021.

The Approved Changes

Deletion of level 1 office new patient E/M code 99201.

(For Medicare, claims for code 99201 represented only 0.15% of all 266 million inpatient E/M claims in 2017, when it had a 37% denial rate (versus an overall E/M denial rate of 5%).

Understand the History and Exam CHANGE before you proceed

AMA’s Panel agreed to the removal of history and exam as key components for selection of the E/M service level. This means that the history and exam would not be used to “score” the visit for an audit. However, the practitioner would be required to document that these elements were performed in order to report an office visit code. Evidence of the history and exam should still be part of the documented record.

Practitioners would select E/M codes based on either 1) the level of medical decision making (MDM) or 2) the total time spent performing the service on the day of the encounter. (Note: “time” will limit you on how many patients you can see per hour).

A plan to revise the E/M guidelines into three sections

  • Guidelines common to all E/M services,
  • Guidelines specific to office and other outpatient visits and
  • Guidelines specific to E/M services in the facility setting, including observation, hospital inpatient, consultations, emergency department, nursing facility, domiciliary, rest home or custodial care and the home setting.

Total time would include “total time spent on the day of the encounter,” instead of total face-to-face time of the visit.

A major overhaul of the MDM documentation guidelines to emphasize complexity of the conditions being addressed in place of the number of diagnoses reported.

Within the office and outpatient E/M guidelines, MDM section title updates would include:

  • “Number of Diagnoses or Management Options” would become “Number and Complexity of Problems Addressed;”
  • “Amount and/or Complexity of Data to be Reviewed” would become “Amount and/or Complexity of Data to be Reviewed and Analyzed;” and
  • “Risk of Complications and/or Morbidity or Mortality” would become “Risk of Complications and/or Morbidity or Mortality of Patient Management.”

Among the additional proposed changes

Prolonged services

AMA proposes to make some changes to other E/M codes; for example, they would revise prolonged E/M or psychotherapy service codes 99354 and 99355, which currently say “in the office or other outpatient setting,” to “exclude reporting of Office and other Outpatient Services codes. Also, a new 99XXX code would be added to “report prolonged office or other outpatient E/M services.” Guidelines would be revised.

Interesting inclusion

AMA proposes to add guidelines for reporting time “when more than one individual performs distinct parts of an E/M service.” This will need to be clarified as to what constitutes the clinical team as part of the encounter.

Summary of changes

AMA proposes to add a Summary of Guideline Differences table to denote the differences between the different sets of guidelines, as well as new definitions of terms, a new MDM table, and definitions of total time associated with outpatient E/M codes. The CPT editorial panel is seeking comments through March 25. Details are available on the AMA CPT website.


(A version of this article was referenced from Part B News)