Overview of the 2021 E/M Guideline Coding Changes

Practices have not seen many revisions to the Evaluation and Management (E/M) office / outpatient visit guidelines in three decades – until now. As of January 1, there are new E/M coding guidelines. We’ll get to those in a bit, but first let’s look at why they changed.

Prior to the 2021 updates, the E/M Coding Guidelines:

…were outdated. Here’s a timeline:

• 1992 – Evaluation and Management codes published in the CPT code book
• 1995 – 1st set of guidelines (1995 Guidelines) published to help quantify E/M codes
• Not supported by specialty providers due to the level of exam – 8 systems is needed for a comprehensive exam
• 1997 – Guidelines published to meet the needs of specialty providers. ED and Family Practice providers found them too cumbersome so CMS decided either set could be used
• 2021 – In 2019 CPT Editorial Panel and RUC workgroup developed new guidelines for 2021

…fostered EHR misuse, namely cloned documentation.

• Medicare (CMS), defines cloned documentation as “multiple entries in a patient’s health record that are exactly alike or similar to other entries in the same patient’s health record or another patient’s health record” (CMS, n.d.) Terms used for duplicative documentation also includes cloning, copy and paste, copy forward, macros, and save notes as a template.

…were burdensome.

• Document to meet bullet points
• Advancement in medical care

…allowed more opportunity for upcoding.

• Payer audits
• CERT Program
• Historical data skewed
• Patient visit frequency
• Note bloat

It’s pretty clear things needed to change. Here’s what’s new in the 2021 E/M Guidelines:

• 99201 – Deleted
• 99202/99212 – Straightforward
• 99203/99213 – Low
• 99204/99214 – Moderate
• 99205/99215 – High

Places of service that will NOT be impacted:

• Hospital Observation
• Hospital Inpatient
• Consultations, Emergency Department
• Nursing Facility, Domiciliary
• Rest Home or Custodial Care and Home E/M Services

Guidelines that will NOT change:

• Definition of New vs. Established Patient
• Appropriate clinical Documentation
• All other E/M Services and calculations
• Incident To Guidelines
• Split Shared Services Guidelines
• Modifier 25

Guidelines that WILL change:

• Removal of history and exam as key components in code selection
  • Select the category or subcategory of service and review the guidelines
  • Review the level of E/M service descriptors and examples
  • Determine level of MDM
  • Select appropriate level of E/M service
• Code selection is based on:
  • Time
    • Time may be used to determine the level of services
    • Office or other outpatient services: total time can be the determining factor in the E/M level assignment.
    • Other E/M service subcategories: time may only be used for selecting the level of other E/M service categories when counseling and/or coordination of care dominate the service.
  • Medical Decision Making
    • Categories
    • The amount or complexity of data to be reviewed and analyzed.
    • Risk of complications or morbidity of patient management can now include social determinants of health
    • Quantifies the numbers of tests ordered, tests reviewed, and/or notes and records reviewed

Here is what our HIA coding experts are seeing during reviews:

“Providers may be able to save some time by documenting a medically appropriate history and exam instead of following the old requirements for those components.”

“Ensuring that labs/tests are not credited multiple times when the labs/tests are ordered at one visit and analyzed at the next visit could be problematic.”

“Providers could be missing out on medical decision-making elements by not documenting things like obtaining information from an independent historian or social determinants of health that could affect treatment.”

“With the removal of credit for a new problem with or without workup under amount and/or complexity of data, it is important the providers fully document their cognitive labor for the visit to obtain credit for all the work required to diagnosis a new problem.”

“For providers who see patients in both inpatient and outpatient settings, the challenge for them is to remember which set of rules applies and to document accordingly.”

“The AMA has provided some clarification for some of the medical decision-making definitions. Assigning the appropriate level will depend on provider documentation so review of the AMA MDM definitions is very important.”