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E/M Coding Changes Medical Practices Need to Know for 2021

November 13, 2020

E&M Codes ChangeMost practices have been working hard to keep up with the Covid-19 and telehealth billing and coding changes – as well as the varying rules between payers lately – over the past six months. But looking ahead to 2021, there are some significant E/M Coding changes coming for the new year.

Previously, in response to complaints by providers and with the executive order from President Trump directing agencies to start cutting red tape, the Patients Over Paperwork initiative was introduced in 2017. That led to CMS proposing revisions to E/M Coding rules that went into effect in 2019, and more extensive changes are going into effect on January 1, 2021.  

It’s essential to get up to speed on these changes and how to prepare for and implement them in 2021, which is why we’ve put together a closer look at some of the major changes, some tips for maintaining compliance, and some suggestions you can follow to prepare for these changes.

CPT Changes in 2021

In the past, CPT codes have referenced the level of physical examination and history. New CPT code descriptors for office and outpatient services for both new and established patients will be based upon the time spent by providers on a patient encounter or the MDM level and the references to both level of history and physical exams have been removed. However, it’s specified that you will need to have a history that’s medically appropriate and/or a physical exam, as well as a specific MDM level.

MDM is Key in Determining Level of Service

For 2021, we’ll be converting to using MDM as the core of your level of coding, and making this change will definitely take some preparation and planning. While choosing a level of service has always included MDM as part of that decision-making process, now it will be the sole way that you decide upon the level of service unless you’re planning to bill based upon time.

For 2021, MDM will be based upon three things:

  • Risk of mortality or morbidity and/or complications
  • The complexity and number of problems being addressed
  • The complexity and/or amount of data that’s reviewed and analyzed

Time-Based Billing

Currently, physicians may use time only to choose an E/M Coding level if over 50% of a patient visit is spent coordinating care and/or counseling. However, this requirement will not apply in 2021. For 2021, physicians are permitted to count their total time on the counter date, even if that doesn’t include care coordination and counseling. This includes both non-face-to-face and face-to-face time a physician spends before, during, and after a patient visit on that day. This may include:

  • Educating and counseling patients, their caregivers, or their family members
  • Coordination of care (when it’s not reportable separately)
  • Ordering tests, procedures, or medications for the patient
  • Documenting clinical information on EHRs (or other types of health records)
  • Performing evaluations or exams that are medically appropriate
  • Referring patient so and communicating with additional health care professionals (if not reportable separately)
  • Doing and/or reviewing a history that’s been obtained separately
  • Interpreting results independently (when not reportable separately) and communicating those results to patients, their caregivers, or family members
  • Preparation to see a patient (i.e., reviewing a previous history, reviewing tests)

Essential E/M Coding Tips for Maintaining Compliance in 2021

What can you do to make sure your practice maintains compliance in 2021 with all the new E/M coding changes ahead? Here are a few actionable tips to remember.

  • Tip #1 – Describe Diagnosis Management – You can’t just choose your diagnosis and leave it like that. If you want to get credit for it, you’ll need to link every diagnosis to an action, whether that’s counseling, a test, prescription, or something else.
  • Tip #2 – Don’t Be Generic With Documentation – Document everything you do thoroughly. If you obtain and review a patient’s medical records, make sure you document the patient, what records you reviewed, and for what treatment dates you were reviewing them.
  • Tip #3 – Keep Documentation Accurate – While you don’t need to itemize your time, you do need to ensure documentation is accurate to avoid raising red flags for payers. For example, be careful when stating the amount of time that you spent with a patient. If your total patient time totals more than a typical workday, it may become a red flag and result in an audit.
  • Tip #4 – Beware of Separately Reportable Services – If separate CPT codes exist for a service you’re completing, then you cannot count that towards your E/M coding level because it’s separately reportable.
  • Tip #5 – Know How Best to Determine Whether to Bill Based Upon MDM or Time – This will always depend on the specific clinical circumstances, but you can ask yourself a few questions to determine which way to bill. If physicians spend a lot of time doing an exam or collecting a patient history, billing based upon time may be advantageous. At times when a physician talks to other doctors or orders multiple tests, billing based on MDM may be the best option. For medically complex patients that require time above and beyond a level five E/M, choosing to bill based on time is beneficial.

Preparing for the 2021 E/M Coding Changes

What can you do to be prepared for the 2021 E/M coding changes? Here are a few suggestions to help you ease through the transition.

  • Learn as much as you can about the upcoming changes. Read, attend courses, or keep up with the latest news surrounding the new E/M coding changes.
  • Consider whether you may need to changes electronic health record templates to work with the changes.
  • Start focusing on documenting important information in notes that will be used in 2021 to score MDM or for time-based billing.
  • Contact payers to discover if they’ll be adopting these changes.
  • Check out your current documentation. Will it support the upcoming changes or do you need to have providers work on improving their documentation to meet new guidelines?
  • Work with a coding expert that’s well-versed in the upcoming changes.

At, we specialize in offering quality medical billing and coding services to practices across the country. We stay up-to-date on the latest billing and coding changes, so we can help your practice ease through the transitions. To learn more about how we can help you navigate the upcoming 2021 E/M coding changes, contact us at 770-666-0470 today for more information.


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