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  • Paragon Health Services

Get Your Practice Ready for Coming E/M Changes

Changes are coming in 2021. New guidelines from the American Medical Association (AMA) in the Current Procedural Terminology (CPT) book on evaluation and management (E/M) go into effect on January 1 of next year. Starting then, physicians and APPs will select an E/M code based on total time spent on the date of the encounter or medical decision making (MDM). This post is an overview of the E/M changes. For a deeper dive, go here.

Determining MDM

Physicians and APPs need a mechanism for the medical record to accurately reflect the effort that they spend delivering patient care. The outgoing guidelines have been viewed by many as overly burdensome. Most physicians and APPs will welcome the changes and the clarity the revisions will hopefully bring.

For 2021, the Centers for Medicare and Medicaid Services (CMS) will move from a points-based system for history, exam and medical decision making, to a pertinent history and a pertinent exam with an emphasis on MDM.

A brief summary shows that for Office/Outpatient E/M services the level of MDM is based on two of the following three elements:

• Number and complexity of problems addressed at the encounter

• Amount and/or complexity of data to be reviewed and analyzed

• Risk of complications and/or morbidity or mortality of patient management

The new rules should reflect the documentation of the care provided. According to, medically necessary services are defined as “health care services or supplies that are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms—and that meet accepted standards of medicine.”


Under the new guidelines, measuring time means accounting for the time spent on the date of the encounter. This includes time that isn’t face to face with the patient, like reviewing the medical record or ordering lab tests. Time spent by clinical staff is not permitted and if more than one provider is involved, only one person is counted per minute.

Physicians and APPs might have some questions about what activities are covered under the new guidelines. Starting next year, the time that physicians and APPs spend delivering healthcare includes the following activities performed during the visit:

• Preparing to see the patient (e.g., review of tests)

• Obtaining and/or reviewing separately obtained history

• Performing a medically appropriate examination and/or evaluation

• Counseling and educating the patient, the family or the caregiver

• Ordering medications, tests or procedures

• Referring and communicating with other health care professionals (when not separately reported)

• Documenting clinical information in the EHR or other health record

• Independently interpreting results (not separately reported) and communicating results to the patient, the family or the caregiver

• Care coordination (not separately reported)

It is essential that physicians and APPs understand that the new rules do not constitute a decrease in documentation or a reduction of supporting facts for a given diagnosis. In fact, the CPT and CMS are raising the bar on the quality of documentation for a given diagnosis.

What Has NOT Changed?

As physicians and APPs adjust to the new rules, it is important to remember the areas that haven’t changed. The guidelines that remain in place include the following areas:

• Documentation requirements for services other than office/outpatient

• Determining if a patient is a new patient or an established patient

• Incident to guidelines

• Modifier 25 (separate E/M on day of minor procedure)

• Modifier 24 (unrelated E/M during post-op period)

• Well visits reported with a “sick” visit

• Multiple visits on the same date of service

• Patients admitted to observation or inpatient status from the office

• Reporting ancillary service associated with an office visit (labs, x ray, etc.)

• Policies associated with teaching physicians not pertaining to documentation and selecting a level of service

• Signature guidelines

Easing the Burden

The 2021 E/M changes to office and other outpatient services are meant to ease the documentation burden on physicians and APPs. When you compare the changes side by side, the new focus is clearly on DOCUMENTING A PERTINENT HISTORY A PERTINENT EXAM AND A MORE DETAILED medical decision making. Keep in mind these important highlights:

  • The updates will be implemented January 1st, 2021.

  • Office or other outpatient services include a medically appropriate history along with a pertinent exam and complexity of MDM

• The updates apply only to Office/Outpatient visits.

New Patient Visits: 99202-99205

NOTE CPT CODE 99201 has been deleted

Established Patient Visits: 99211-99215

• The level of service may be based on complexity of MDM or total time on date of service

With the proper planning, education and implementation, these changes will have a positive impact on both the provider workload and quality of patient care. At Paragon, we focus on accurate, up-to-date information for our clients. As significant changes to rules of coding and documentation come, we will share that information to help our physicians and APPs stay informed as they continue to give their patients the best care possible.

For more information, consult the AMA’s 2021 Guidelines and Checklist.

Information in this post is created based on Paragon Health Service’s experience on this particular topic. Please refer to your local Medicare/Medicaid Carrier, CMS, OIG and/or insurance payers for all requirements.

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