8/19/2021 New E&M Coding and Documentation Guidelines for 2021

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New E&M Coding and Documentation Guidelines for

2021
This article will address the 2021 E&M reimbursement changes with medical
decision making and the recording of time spent with patients.
By Rupal Trivedi, CPC, CPMA - Manager, Physician Services and Brian Herdman, Operations Manager -
Financial Reimbursement Services 

The American Medical Association (AMA) and Center for Medicare and Medicaid Services (CMS) will be
implementing changes to Evaluation and Management (E/M) services for office or other outpatient E/M (99201-
99215); all other E/M services will remain unchanged. CMS launched the Patients over Paperwork initiative in
2017 to reduce documentation overall and provide more time with patients. As of Jan 1, 2021, providers will
select E/M services based on the level of the medical decision making as defined for each service or total time
spent on the date of the encounter.

(https://attendee.gotowebinar.com/register/7401789545011609359)

This article will cover many of the major changes to Medical Decision Making (MDM) that are associated with
the new Rule and provide examples of how reimbursement can be subject to change with the new regulations.

The current process for selecting the office and outpatient (99201-99215) E/M codes uses three key
components for determining the level: History, Examination, and MDM. Beginning Jan 1, 2021, history and
exam are no longer to be counted as key components selection of an E/M, but will still need to be documented

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8/19/2021 New E&M Coding and Documentation Guidelines for 2021

as medically appropriate. CPT code 99201 (Level 1 new patient)

will be eliminated. CPT 99202-99215 will be selected based on
medical decision making or total time spent with the patient. Also,
there will be a new CPT code, 99417, to report prolonged services
in conjunction with 99205 and 99215.

Here are three important things to know about the coming

changes.

1. MDM will be the key factor for selecting the level of service

The three categories for determining MDM has been updated with
more specific definitions. 

Elements of Medical Decision Making

These new definitions will have a significant impact on how MDM is currently scored and how it will be
calculated in 2021. Below are two examples comparing differences between current guidelines and those being
implemented in 2021:

A. Patient presents with an acute fever, abdominal pain, and painful urination for two days. The provider
documents the medical history and exam. The provider orders a urine analysis, which comes back positive and
prescribes an antibiotic.

In 2020, we would give three diagnosis points for a new problem with no additional workup. For data, one
point for ordering theurine analysis, and table of risk would be moderate for prescription
drug management.  The E/M level assigned tothis would be 99214.  
With this same scenario using the 2021 MDM table,the problem is acute and uncomplicated, the amount
of complexity is limited,and risk of management falls under “moderate” due to prescription
drug management. Applying two of three MDM elements with 2021 guidelines, the level of service
supported would be 99213.
B. Now let’s consider an established patient who has a follow up office visit for asthma management. The
provider documents a medically appropriate history and exam and reviews an independent interpretation of a
pulmonary function test. The provider makes a change to current medication and sends to the pharmacy.

Utilizing the 2020 scoring tool, we would assign one point for the stable chronic diagnosis, two points for
the independent interpretation of the PFT test, and risk would be moderate. Overall, this would be a low
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8/19/2021 New E&M Coding and Documentation Guidelines for 2021

complexity and the E/M level would score to a 99213.

In the 2021 MDM table, the number and complexity of the problem addressed meets one stable chronic
illness, which supports a low level. The provider reviewed and independently interpreted tests which falls
under a moderate level for amount and/or complexity of data. Finally, the risk of complication is moderate
due to prescription drug management. Since we have two elements that would be categorized as
moderate, this would support the assignment of 99214.

The outcome of many visits will change in 2021 due to the history and exam no longer being a factor. As you
can see from both of the examples, there will be significant changes on how we score the MDM for office visits.
The revised Rule has also introduced some social determinants of health (SDOH) as valid risks of
complications, potentially elevating the risk level of visits due to underlying conditions. SDOH typically include
homelessness, food insecurity, and economic insecurity. Capturing SDOH via ICD-10-CM diagnosis codes (e.g.,
Z59.0 for homelessness or Z59.5 for extreme poverty) may help support a more complex MDM.

2. Total Time

In 2021, time will be defined as total time spent, including non-face-to-face work done on that day, and will no
longer require time to be dominated by counseling. This will allow one to calculate pre- and post-time (time
spent before or after meeting with the patient), and time spent meeting with the patient during the visit.

For example, this would include communication with a referring physician and ordering tests for the same
calendar day. It is important to note that only the billing professional’s time is counted; the clinical staff time is
excluded from the time count.

The new guidelines establish the standard time threshold for each of these codes. Each visit will have range of
time; for example, CPT 99213 will be 20-29 minutes and 99214 will be 30-39 minutes. 

3. New Prolonged Service Code

Beginning in 2021, there will be a new code for reporting prolonged service with an office visit. The new
prolonged service CPT code 99417 will be in increments of 15 minutes. The revised guidelines include
prolonged service codes 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.

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8/19/2021 New E&M Coding and Documentation Guidelines for 2021

In summary, the current system relies on documentation of a series of points for history and physical exam to
support the visit level. The new system relies on documentation of points for diagnoses or treatment options,
amount and complexity of data reviewed, and risk of complications. It is not enough for the provider to select the
diagnosis; he or she will have to describe the diagnosis management. The new method in determining the E/M
level will require the provider to be more detail-oriented in medical decision making.

CBIZ has been assisting clients in preparation for the 2021 E/M changes. We offer both modeling services and
chart reviews to help hospitals plan for reimbursement, provider compensation and compliance factors that will
result from these changes. For additional information, please contact Adam Abramowitz at
[email protected] (mailto:[email protected]) or 609-220-5627.

CPT Copyright 2020 American Medical Association. All rights reserved. "CPT® is a registered trademark of the
American Medical Association." 

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