Office Evaluation and Management Coding Changes Effective January 1, 2021

E&M Changes 2021

Centers for Medicare and Medicaid Services (CMS) will be implementing E/M office coding guidelines and pay rate changes effective January 1, 2021. Documentation requirements and time-based coding is changing! Overall documentation will be less cumbersome.

Highlights of CMS E/M Guidelines for 2021:

• The history and physical exam will no longer be used in the code selection. Instead the focus will be on the medical decision making
• Medical decision making (MDM) will not be based on a point system, but instead will be related to tasks necessary to take care of patients.
• The time-based counseling and coordinating care is shifting to total time, so non-face-to-face services can be incorporated into the time. The time for each level of service has increased.
• 99201 is deleted

Evaluation and Management Coding Cheat Sheet 2021:

Two choices for selecting the level of Service: Medical Decision Making or Time

*Source CPT 2021

Medical Decision Making

Tasks such as ordering tests, interpreting tests, discussions with other healthcare providers, review of notes should be clearly documented. Diagnoses should be identified as acute or in exacerbation status if applicable. Decision/discussion about testing, surgery, treatment plan, social determinants, drug management, and risks should all be clearly documented.

While there may not be a coding requirement as it relates to history or exam, what is documented in the history and/or exam will help support medical decision making AND medical necessity. Additionally, there is also the need for providers to protect themselves from medical liability.

Time Based Coding

Document tasks, discussions, review of records, etc. Add it all up (both face to face and non-face-to-face). DOCUMENT THE TIME!

E/M Office Visit Codes

Prolonged visits codes will not be allowed any longer for the office visits EM. Instead, there will be a new add on code for a prolonged visit beyond the 74 minutes for new and the 54 minutes for established.

EMR

Work with your EMR vendors to make certain templates are set up appropriately for the coding changes.

What do you think about these changes? More to follow next time..

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