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Big Changes are Coming in Payment and Documentation Guidelines

July 21, 2020

Payer-Contract-Negotiation-2The Centers for Medicare & Medicaid Services finalized their Fee Schedule included some pretty significant changes to reimbursement and documentation requirements for evaluation and management also known as E&M office visits. But, most of the changes won’t be taking effect until Jan 1, 2021, which means the time to begin preparing is now.

While CMS had delayed E&M coding reforms, particularly because many doctors were balking at the changes that included transforming the now-used five-tier E/M system into one that has blended payment rates for outpatient and office visits being billed at the second through the fifth levels. The goal of these changes is to help reduce the red tape that often leads physicians to burnout, but many worry about potential unintended consequences, leading to the delay. However, 2021 is coming, the changes are still scheduled, and it’s time to start preparing. 

2021 Changes to Documentation Requirements 

On January 1, 2021, providers will be offered the flexibility to document level two through five E/M outpatient and office visits in the following ways: 

For providers who document based upon the time they take, they’ll need to document medical necessity, as well as the face-to-face time spent with a patient. If the visit is a level 5 established patient visit, then the time spent on coordination of care and documented counseling has to exceed 20 minutes, and for a level 5 new patient visit, that coordination of care and documented counseling time has to exceed 30 minutes. 

To document using medical decision making (MDM) or the ’97 or ’95 guidelines, minimum documentation for outpatient/office visit levels between 2 to 4 are required, meaning provides must document: 

  • Problem-focused history not including social, family, or past history or a review of systems.
  • Limited exam of the affected organ system or affected body area
  • Very straightforward MDM that’s measured by minimal risk, data review, and problems (two out of three). 

For physicians documenting on MDM alone, then only documentation that supports straightforward MD is required. 

Reimbursement Changes for 2021 

Significant changes are coming for provider reimbursement in 2021 as well. This will be done by consolidating payments for the E/M levels 2 through 4 into one rate (there’s one rate for established patients and one rate for new patients). However, separate payment rates for both level 5 and level 1 visits will continue. 

These new rates were calculated by CMS by considering the utilization rate of these outpatient/office E/M services between 2012 and 2017, calculating a rate weighted by the frequency at which these services are billed currently. 

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New Add-On Codes for 2021

New add-on codes are coming for 2021 as well, and they’re designed to help reimburse physicians for outpatient/office E/M levels 2 to 4 for patients who require more complex care, since the resource costs of those visits are often not fully captured within the proposed single payment rate that will be coming in 2021. The new HCPCS add-on Level II codes include: 

  • Code GPC0X – Non-procedural Specialty Care Complexity – Complexity of the visit that’s inherent to management and evaluation associated with specialty, non-procedural care including interventional pain management, neurology, endocrinology, infectious disease, pulmonology, urology, endocrinology, cardiology, psychiatry, rheumatology, obstetrics/gynecology, otolaryngology, nephrology, and hematology/oncology.
  • Code GPC1X – Primary Care Complexity Code – Complexity of the visit that’s inherent to management and evaluation associated with primary medical care services serving as the ongoing focal point for all additional healthcare services. 
  • Code GPRO1 – Extended Visit Code – Used for additional time for evaluation and management services offered in outpatient or office settings when the visit requires direct patient contact of between 24-69 face-to-face minutes for an existing patient, or for new patients, 38-89 minutes. Should be listed separately in addition to the 2-4 outpatient/office E/M visit. 

Also, don’t forget that physicians also can use the psychotherapy services code (+99354) or prolonged E/M services code (+99355) with all outpatient/office E/M visit levels.  

Preparing for 2021

Although there’s likely to be some clarification coming from the CMS before 2021, there are still some things that can be done now to start preparing for these upcoming changes. One of the best ways to prepare is to ensure providers are educated in the coming changes. While these changes are designed to help reduce the documentation burden on physicians, that won’t work if they’re not aware of the new guidelines. Providers must understand the requirements for time-based reporting and be aware of the newly changed MDM table that includes simplifications and clarifications from the MDM table being used currently. Practices need to start educating providers now on the new documentation requirements and on how the new payment schedule will work to prevent mistakes that result in denials.

At, we’re here to help, both as you move into 2020 and as you prepare for the upcoming changes in 2021. We specialize in medical billing and coding, and we’re here to help. Our experienced staff stays on top of the latest payer guidelines, ensuring you minimize missed payments and lost claims. Contact us today at, by email, or by calling 770-666-0470 to learn more about how we can help you in the coming year.


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