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Sweeping Changes for E/M Coding Are on the Way – What Do They Really Mean?


Come 2021, outpatient evaluation and management, or more commonly known as E/M coding is getting a massive overhaul and will considerably impact how care is documented and reported. This past August, the Centers for Medicare & Medicaid Services (CMS) confirmed that several previously announced changes to E/M guidelines and pay rates for outpatient and office visits are going into effect January 1, 2021. For now, these updates will apply only to Medicare patients, although many expect other payers to closely follow suit in the coming months and years.

Many of these changes are designed to streamline documentation and reduce administrative burden in response to years of provider feedback. The new E/M guidelines should also help increase reimbursement for outpatient and office visits, although the increases will initially be offset by payment reductions of other services – much to the American Medical Association’s dismay.

These sweeping changes will have a significant impact on providers and coders alike – and a comprehensive understanding of the changes is the first step toward successful adoption of the new guidelines.  While most organizations have been preparing for these changes since they were announced in 2019, now is the time to fully prepare, educate, train-up, and communicate within your organization.

Areas of Greatest Change

When it comes to the new guidelines, most of the changes relate to medical decision-making (MDM) and time. Here’s a brief summary of the most notable changes to come.

  • The Choice is Yours. One of the most substantial changes is giving providers the power to decide whether documentation is based on total time or medical decision-making. This allows providers to better capture time spent delivering care that isn’t necessarily face-to-face such as coordinating care, reviewing test results, etc. Previous guidelines required face-to-face time to account for more than 50% of the visit to choose a code level based on time.
  • Medically-Appropriate H&P. A huge time-saver for providers, the new guidelines will only require a medically-appropriate history and/or physical examination – and they are no longer required for code selection. Previous guidelines required review and examination for a defined number of body systems. The guidelines state: “The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified healthcare professional reporting the service. The extent of history and physical examination is not an element in selection of office or other outpatient services.” This will save providers plenty of time in unnecessary documentation.
  • Medical Decision-Making Is The Focus. Instead of adding up tasks, 2021 guidelines move to focusing on those tasks that have an impact on the patient’s condition. The four types of MDM include: straightforward, low, moderate, and high – which vary based on the number and complexity of problems addressed; the amount and/or complexity of data to be reviewed and analyzed (such as records, test results, interpretation of tests, and discussion of such tests with other physicians and/or qualified healthcare professional or source; and finally, the risk of complications and/or morbidity or mortality of patient management. One important change here is that underlying conditions and/or comorbidities can’t be considered when selecting an E/M unless they are addressed in that visit and they increase the amount of data to be reviewed or impact morbidity/mortality of patient management.

It’s About Time. 2021 guidelines state that time is defined as “total time spent on the day of the encounter.” This could include:

  • Time spent preparing for a visit (i.e., reviewing test results, history, etc.)
  • Getting patient history from patient or history obtained separately (i.e., from another provider or medical record)
  • Performing the exam and/or evaluation (as deemed medically necessary)
  • Educating and counseling the patient and/or their support people (family and/or caregiver)
  • Ordering tests, medications, and/or other treatments
  • Communicating with other health care professionals, to include referring physicians or other providers involved in care of the patient
  • Documenting clinical information in the patient’s medical record (ONLY time spent the day of the appointment counts)
  • Interpreting and sharing test results with the patient
  • Coordinating patient care

Time calculated should NOT include activities performed by clinical support staff (medical assistant, etc.) such as taking vitals, height, weight, etc. Note: Providers who choose level of service based on time should be careful to be accurate in their recording of time to avoid False Claims Act allegations. Several instances have been reported where physicians have been investigated for overinflating time spent above and beyond a normal workday.

While these changes should ultimately save providers a great deal of time – it will undoubtedly impact clinical, operational, and financial performance, making it imperative to engage providers and coders now, in order to supply ample education and training on all new requirements prior to January 1, 2021.  A proactive approach will not only ensure accuracy, but also a smooth and compliant transition.

GeBBS’ dedicated experts can help you ensure smooth transition while safeguarding accuracy and compliance. To learn more visit: www.gebbs.com

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