Answers to AMA/CPT® 2021 E/M Documentation rules and Errata Clarifications

Ever since the release of the new 2021 Evaluation and Management (E/M) guidelines for Office and Other Outpatient Services, ICD10University has been conducting numerous provider and staff educational training sessions through Webcasts, articles, and session spotlights on’s Talk Ten Tuesday live broadcast and podcast.  In this article, we will answer the Top 10 questions we continue to receive from our listeners and clients.

Can the Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 documentation guidelines still be used?

You should continue to use the CMS 1995 and/or 1997 Documentation Guidelines for Evaluation and Management Services for all E/M categories except office/other outpatient services (99202-99215). Use the 2021 CPT® documentation guidelines for office visits (99202-99215), only.

Do you have to document both total time and medical decision-making (MDM)?

The provider is not required to document both total time and MDM (medical decision-making). They can select whether total time or MDM best represents the work performed for each encounter. The provider should level their code based on the best circumstance for the encounter.

Discussed during our most recent EM 2021 Auditing Webcast, we polled our audience on whether providers thought the total time of the encounter or MDM best represented their work and the majority answered MDM. The case studies that were offered, also reflected that MDM was much easier to support higher levels of service than the time threshold.

We recommend that using “time” to level your encounter may be most appropriate for instances when the patient has multiple tests or treatment options that must be reviewed, or the patient/caregiver has a lot of questions or counseling the patient on the best treatment plan takes an unusually long amount of time.

This is a “Best Practices” case scenario where basing code selection on time may allow you to report a higher-level visit that more accurately represents the provider’s work.

What is the best way to document total time?

To properly document total time, AMA instructs that the provider needs to document the activities performed and include a statement of the total time for the encounter.

Since you cannot include the time spent performing other billable services (for example, interpretations that are billed separately, minor procedures, care coordination performed by ancillary staff), it is recommended that the provider includes a statement that the total time does not include the time spent performing other billable services. (e.g., the skin tag removed from the patient’s right armpit took 16 minutes that was not included in the total time of the visit, and was billed separately).

A frequent question our ICD10University educators have received is if it is required to document the time increments associated with each activity (for example, 5 minutes spent reviewing records, 10 minutes spent examining the patient and answering all their questions, and 10 minutes ordering tests and documenting in the medical record). There is not an official source stating that time must be documented incrementally, just that total time must be documented.

However, if your encounter is ever audited by a payer, it is recommended that your statement does include specific services with the total time spent to support your time as a qualifying leveling option.

If you are coding based on the total time, does the time a medical scribe spends documenting in the electronic health record count?

No, only the activities the provider personally performs can be included in determining total time. Clinical staff time cannot be included in the total time billed for the E/M code. We are also often asked if you can count resident time.

The answer is “no” as well.

The teaching physician guidelines have not changed. When residents are involved in performing any service that is coded based on time, only include the time of the teaching or supervising physician.

Can you count the order of a test that is interpreted and billed by the provider?

If the provider is performing and billing the interpretation, the order cannot be counted as data under MDM. For example, your provider orders a chest x-ray and an EKG during the face-to-face encounter, and bills for both of those services. They cannot count towards the Data Points under the MDM nor can you count the time to order or perform those services, as they are “separately reported”. There is no double-dipping.

The AMA’s technical correction (Errata) states, “The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.

Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation but may be counted as ordered or reviewed for selecting an MDM level.”

What this means is that if your provider reviews an x-ray for example that was taken in the ER and sent over for review by your physician with the patient, and the physician just went over the results with the patient, then you would count this “review of a unique test” under Cat 1 of the Data Points Element.

On the other hand, if this review included a more detailed, documented interpretation of the film by your physician in determining the next step of care, and again, well documented (not necessarily a formal interpretation), then this could be considered under Cat 2 of independent interpretation of a test performed by another provider that you did not separately report.

Can you count the order of a test on one date of service and the review of the same test when the patient returns for the next encounter?

No. You can count the ordering of the test during the visit when it’s ordered, but the subsequent review is expected to be performed when the test is ordered. You cannot give credit for the review of a test if credit was already given for the order, again AMA considers this double-dipping. It will be a challenge for auditing and CDI staff to determine when the test was ordered and reviewed to make sure credit is given at the appropriate encounter.

This makes sense if you think of this scenario in the practical sense of how patient care is delivered. The patient is seen, and the provider orders tests. The provider will likely review the test results as soon as they become available. The provider will rarely wait until the next face-to-face encounter with the patient to review the test results, even though at some point the patient will be given the results.

Another typical scenario is the provider orders tests when the patient is seen, reviews the test results, and based on the results, orders additional tests. In this scenario, you would give credit for the review of the results of the next series of tests because they were ordered after the patient was seen and the order was not counted as data at the previous visit.

Can the physician include ordering preventative services tests like screening mammograms or screening colonoscopies for age-appropriate patients, in their MDM risk or in the “time” factor when leveling an encounter?

No. Per AMA and NAMAS, unless the testing has a direct bearing on “problems addressed” then simply adding or ordering preventative services that do not factor into the MDM of a problem-oriented visit, are not counted or time or MDM elements.

When a specialist sees a patient and sends a note back to the referring provider (PCP) is this considered a “Discussion of management with an external provider” under the Category 3 Data Point element?

No. CPT® Errata clarified what “discussion” means:

“Discussion: requires an interactive exchange. The exchange must be direct and not through intermediaries (e.g., clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange.

The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision-making of the encounter. It may be asynchronous (i.e., does not need to be in person), but it must be initiated and completed within a short time period (e.g., within a day or two).”

Now in saying that, the AMA direction for 2021 has been that to include any MDM elements or time elements that the work has to be on the same date as the “face-to-face” encounter; so this seems to be an exception. A little advice here would be to include this exchange if it is on the same date so that the record is not left open to wait for a return call back from the external provider.

When reviewing an external note, does each test and progress note count separately?

No, all the information from the unique source would be counted as one Data Element under Cat 1. This is clarified in the technical corrections released in March 2021 by the AMA: A unique source is defined as a physician or qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.

When a patient requires a translator during their encounter, can this be counted as an “Independent Historian” under Cat 2 for low MDM or Cat 1 for moderate MDM?

No. Use of a translator does not count for independent historian since the patient is still giving the history.

However, if using “time” to level your visit, include the extra time it took to use a translator if that factored into a longer encounter. If the provider is the translator and extra time was not needed, then this would have no bearing on MDM or time.



CPT ® AMA Errata – Corrections 2021 5.3.2021