Major Changes Are Coming for E/M Visits in 2021–Are you Ready? (Part 1)

The updated code set is “the first major overhaul in more than 25 years to the codes and guidelines for office and other outpatient evaluation and management (E/M) services,” according to the American Medical Association (AMA).

Outpatient Codes Receive Overhaul

The changes were designed to make E/M office visit coding and documentation simpler and more flexible, freeing physicians and care teams from clinically irrelevant administrative burdens that led to time-wasting notes and paperwork. The revised E/M office visit codes are among 329 editorial changes in the 2021 CPT code set, including 206 new codes, 54 deletions, and 69 revisions.  

Among this year’s important additions to the CPT code set are new medical testing services sparked by the public health response to the COVID-19 pandemic. The CPT code set has been modified with several code additions and revisions that have been approved for immediate use and published for the 2021 CPT code set. 

The documentation guidelines set by the Centers for Medicare & Medicaid Services (CMS) for E/M services were established 20 years ago and served as a scoring system to justify a level of billing (level 3, 4, or 5). Adherence to E/M documentation guidelines consumes a significant amount of physician time and does not necessarily reflect the actual work of physicians. 

Due to stakeholder complaints, CMS Administrator Seema Verma launched the Patients Over Paperwork initiative in 2017 in accord with President Trump’s executive order that directed federal agencies to cut red tape. In response, CMS proposed revisions to the E/M rules, which went into effect on Jan. 1, 2019 reducing the redundancies of documentation for outpatient visits. 

More extensive changes will go into effect on Jan. 1, 2021.  The changes include extensive E/M guideline additions, revisions, and restructuring; the deletion of code 99201 and revision of codes 99202–99215.  

Code-level selection should be based on medical decision-making (MDM) or total time on the date of the encounter. The creation of a 15-minute prolonged service code is to be reported only when the visit is based on time  and  after the total time of the highest-level service (e.g., 99205, 99215) has been exceeded. 

Although the history and physical exam elements are recorded, they do not factor into the level of service. 

Current Procedural Terminology (CPT) Changes 

The AMA has created new CPT code descriptors for office or other outpatient services (new and established patients) that can be based upon the level of MDM or the time spent by the provider on the encounter. 

For each code descriptor for these services in CPT, all references to the level of history and physical examination are removed. Instead, it is specified that there must be a medically appropriate history and/or physical examination and a specified level of MDM. 

Time as a Determinant of Level of Service 

For providers who wish to bill by time, the length of time corresponding to each level of a visit is specified. Note that the current time rules for coding apply when counseling and/or coordination of care dominates the encounter and includes only face-to-face time in the office. Starting in 2021, providers who wish to code by time spent may include all related activities on the day of the encounter.

MDM as the Prime Determinant of Level of Service 

It is expected that the conversion to MDM as a basis for the level of coding will require some planning and preparation on the part of qualified healthcare providers. MDM has always been part of the algorithm for choosing a level of service but will now be the sole determinant of the level of service unless the provider intends to bill based on time. 

MDM in 2021 will be based on the number and complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and/or morbidity or mortality. 

Number and Complexity of Problems Addressed at the Encounter 

The greater the number and complexity of problems addressed at the encounter, the higher the applicable level of decision-making is necessary. This ranges from straightforward to low, moderate, and high. 

Several specific problem level options are listed ranging from self-limited or minor problems, to acute or chronic illness, or injury that poses a threat to life or bodily function. 

Amount and/or Complexity of Data to be Reviewed and Analyzed 

This category attempts to quantify the amount of data, efforts to gather data, and communications utilized to evaluate a patient. The collection of more data leads to a higher level of MDM. Levels include minimal or none, limited, moderate, and extensive.  

Data are 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 healthcare providers/appropriate source (not reported separately) 

Risk of Complications and/or Morbidity or Mortality 

This is an assessment of the relative danger of patient management—whether from treatment or further work-up. Levels are minimal, low, moderate, and high. Some treatments are relatively risk-free, others are highly risky, such as a decision about an emergency major surgery. 

Once the level of the presenting problem is established, the data is reviewed, and risk management is determined, the overall level of MDM can be determined. To qualify for a particular level of MDM, two of the three elements for that level of decision-making must be met or exceeded. That will determine the level of E/M service.

 To estimate the number and complexity of problems, the amount and complexity of data, the risk of complications, morbidity, or mortality, it may be helpful to become familiar with the definitions. The definitions and new code guidelines are all available on the AMA website.