E/M Coding Guidelines Are Changing. Is Your Practice Ready?

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You could say that for the past few years, Evaluation and Management (E/M) codes have been stuck in the 90s. Many of the guidelines haven’t changed since 1995 or 1997, and they are notorious for their burdensome documentation requirements that, among other things, ask doctors to evaluate body systems that may not be pertinent to the patient’s visit. This adds up to more time spent on documentation and less time spent with the patient. However, E/M coding guidelines are changing in 2021 and you’ll want to make sure your staff AND your EHR are ready.

Is your EHR ready for January’s E/M changes? Find out and test your knowledge with our quiz. >>

Here’s what you need to know about January’s E/M changes:

E/M Coding Changes Are Coming in 2021

The first thing you need to know about these changes is that they go into effect on January 1, 2021. These are the first sweeping changes in over 20 years and they were years in the making. It began with CMS’s initiative, Patients Over Paperwork, which seeks to remove the obstacles that keep doctors from spending more quality time with their patients.

Here are some quick facts about the history behind the changes:

  • CMS has indicated that these changes are intended to relieve the documentation burden that E/M coding places on physicians
  • CMS originally proposed more changes, but they were met with resistance
  • The new guidelines reflect revisions made by The American Medical Association (AMA)

2021’s E/M Coding Changes Are Not Just for Medicare

The American Medical Association has made edits to the latest edition of their medical coding manual, CPT 2021. In other words, these latest changes are not just a Medicare change, they are changes to the national coding guidelines. However, for our ophthalmology clients, the new guidelines will not affect eye codes.

History and Physical Exam Are Eliminated as Elements for Code Selection

According to the AMA, the new guidelines also eliminate “history and physical exam as elements for code selection. While significant to both visit time and medical decision-making, these elements alone should not determine a visit’s code level.”As of 2021, the nature and extent of the patient’s history or physical exam is determined by the physician or the non-physician practitioner reporting the service.

Clinicians Will Now Bill Based on MDM or Time

Remember those telemedicine reimbursement guideline changes that happened back in the spring of 2020? If so, you know that clinicians were instructed to bill for telehealth (codes 99201-99215) based on MDM or time. So, if you’ve used telehealth in the last few months, you’ve given yourself a preview of what January’s changes will be like.

How do January’s changes differ from the changes adopted earlier this year? In addition to the emphasis we saw previously on billing by MDM or time, the new changes:

  • Remove code 99201
  • Apply to office and other outpatient services
  • Include revisions to the prolonged services CPT codes.

Billing Based on Time

One criticism of the previous E/M coding guidelines was that clinicians would put in a lot of work to treat their patients—documenting the exam, ordering tests, reviewing results, making referrals, etc.–and the way the visit was coded (and subsequently reimbursed) often didn’t fairly compensate the provider for the time spent with the patient.

Come January, time alone may be used to select the appropriate code level for the following office and outpatient E/M services codes:

  • 99202
  • 99212
  • 99203
  • 99213
  • 99204
  • 99214
  • 99205
  • 99215
  • The new guidelines take the work a provider may do to prepare for and follow up on a patient appointment more into account.  And if the physician documents based on time, they can now bill for non-face-to-face time, a key differentiation from the previous guidelines.

    Starting in January, physicians will be able to bill for time spent on:

    • Performing a medically appropriate examination and/or evaluation
    • Documenting clinical information in the patient’s chart
    • Ordering medications, procedures or tests
    • Coordinating care (when not separately reported)
    • Referring to or communicating with other healthcare professionals (when not separately reported)
    • Preparing for the patient visit
    • Obtaining and/or reviewing separately-obtained history
    • Counseling and educating the patient, the patient’s family or caregiver
    • Independently interpreting results (where not separately reported) and communicating results to the patient, the patient’s family or caregiver

    It is worth noting that the time providers spend together, meeting with or discussing the patient, should be counted only once (like you’re counting the time of one individual). And, the time spent by clinical staff on a service cannot be included in the calculation of total time for the purposes of code selection.

    Billing Based on Medical Decision-Making (MDM)

    For office or outpatient services, there are three elements of medical decision-making.

    For 2021, these are defined as:

    • The number and complexity of problems addressed
    • Amount and complexity of data to be reviewed and analyzed
    • Risk and/or morbidity or mortality of patient management.

    However, certain aspects of these elements will change in 2021, and while they may seem subtle, they could have a major impact on how physicians are reimbursed.

    Here are some of the key changes related to documenting based on MDM:

    • Four types of MDM are recognized: straightforward, low, moderate and high.2
    • The medical decision-making criteria will also “move away from simply adding up tasks to instead focus on tasks that affect the management of a patient’s condition,” according to the AMA.1
    • Also, with regard to tests, documents, orders, or independent historian(s), AMA reference materials state that “each unique test, order, or document is counted to meet a threshold number”3
    • The 2021 MDM guidelines defines shared MDM and state that “MDM may be impacted by role and management responsibilities.”1
    • The 2021 MDM table references social determinants of health as “an example of moderate risk from additional diagnostic testing or treatment.”3

    The AMA provided the following medical decision-making table as a resource for physicians:


    Source: The American Medical Association

    Prolonged Services Coding Changes

    Prolonged services codes are typically used when E/M services extend beyond the total time identified with the code level that would otherwise be billed for the primary procedure.

    Here are some of the changes that apply to these codes:

    • 99417 is new and can be used in conjunction with 99205 or 99215
    • These codes apply to face-to-face time and non-face-to-face time
    • Less than 15 minutes will not be considered “prolonged”

     The AMA provided the following prolonged services tables as resources for physicians:

    Prolonged Service Without Direct Patient Contact

    Total Duration Code(s)
    Less than 30 minutesNot reported separately
    30-74 minutes
    (30 minutes - 1 hr. 14 min.)
    99358 X 1
    75-104 minutes
    (1 hr. 15 min. - 1 hr. 44 min.)
    99358 X 1 AND 99359 X 1
    105 or more
    (1 hr. 45 min. or more)
    99358 X 1 AND 99359 X 2
    or more for each additional
    30 minutes.

    Source: The American Medical Association

    Prolonged Service With Direct Patient Contact

    Total Duration Code(s)
    Less than 30 minutesNot reported separately
    30-74 minutes
    (30 minutes - 1 hr. 14 min.)
    99356 X 1
    75-104 minutes
    (1 hr. 15 min. - 1 hr. 44 min.)
    99356 X 1 AND 99357 X 1
    105 or more
    (1 hr. 45 min. or more)
    99356 X 1 AND 99357 X 2
    or more for each additional
    30 minutes.

    Source: The American Medical Association

    A New Medicare HCPCS Code: GPC1X

    Specialists who need to document medical services that are part of ongoing care will want to know about this new Medicare add-on code.

    The CMS describes GPC1X as, “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious or complex chronic condition.”4

    Quick facts about the GPC1X:

    • It’s used in conjunction with 99205-99215
    • It’s listed separately in addition to an E/M code

    What Modernizing Medicine Is Doing About the E/M Changes

    There are a lot of positives about these new E/M guideline changes. However, that doesn’t mean there isn’t going to be a learning curve for medical practices. Our EMA® and gGastro® EHRs will, of course, be updated to assist our practices more easily comply with these latest changes. But one thing practices should keep in mind is that an intelligent EHR system can help make your transition to these new changes easier right out of the gate.

    Is your EHR ready for January’s E/M changes? Find out and test your knowledge with our quiz >>

    For example, the suggested coding function of our EHR systems has been updated to such that the suggested medical coding will, as of January 1, 2021, be consistent with the new coding requirements adopted by the AMA and CMS, as supported by your clinical documentation. The systems will also be configured to enable providers to choose to bill based on MDM or time. Providers can always go back and make adjustments to any of the three levels of decision-making, without overriding the system, and, as always, providers can review and approve of, or make changes to, the coding suggested by the system before a bill is created or submitted. No extra lookups or calculations needed.

    A preview of the Medical Decision-Making functionality in EMA.

    In her former life, Ronda Tews, our Director of Billing and Coding Compliance, used to do consulting and audits. Ronda was part of the team working on these important updates and notes that:

    “There aren’t any other EHR systems that I’ve come across that have the capability to be as specific as we are with that medical decision-making and it’s because of all of the plans our medical directors have written that are specific to a diagnosis and specific to a treatment. No other EHR is like that.” 

    Ronda Tews, Director of Billing and Coding

    at Modernizing Medicine

    Learn how you can make the transition easy for your office with EMA or gGastro, and take our quiz to test your knowledge.

    Related Content You May Enjoy

    1The American Medical Association: August 4, 2020, E/M Office-Visit Changes on Track for 2021: What Doctors Must Know.” 

    2CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX).

    3The American Medical Association: Evaluation and Management Office Visits 2021, slide deck, pages 45 and 51.

    4Calendar Year (CY) 2019 Medicare Physician Fee Schedule (PFS) Proposed Rule, page 11.

    The materials included in this blog were current as of November 13, 2020 and may be subject to change. Updates and details on the topics contained herein may be available from the CMS, the CDC, and other commercial payers. Modernizing Medicine makes no warranty regarding the ongoing accuracy of the information provided.

    This blog is intended for informational purposes only and does not constitute legal or medical advice. Please consult with your legal counsel and other qualified advisors to ensure compliance with applicable laws, regulations, and standards. It is each provider’s responsibility to determine that any telemedicine visit meets medical necessity for a given patient. Not all clinical scenarios may be appropriate for telemedicine visits, and the provider may need to evaluate the patient in person to establish a diagnosis or initiate treatment.


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