Major Changes to E/M Guidelines for 2021

 In Blog

Anticipation of the BIG changes in the E/M Code Guidelines for 2021 has been building for several years. CMS has been moving toward this change for a long time by increasing the weight of Medical Decision-Making and making Medical Necessity the overarching criterion for support of the level of service, rather than the extent of the documentation in the History and Exam. In the new system, the History and Exam will no longer be scored. You read that correctly. Those elements are entirely up to the provider based on the patient’s needs in the encounter. The actual changes are easy to illustrate but require shifts in perspective, as well as changes to EMR templates. Some good news is that the original proposal to blend payment rates was abandoned, so rates will still increase as the level of services increases.

Review the information below as an indicator of the new guidelines, and keep in mind that MMG will offer personal instruction to any questions or concerns for individuals or group settings. Please contact any of our team members for more information.

Easiest Things First

CPT 99201 was deleted and will not be replaced. This decision was based on reasoning that the level of care provided to a new patient always requires more from the caregivers than is covered by this low-level service.

EMR Changes

The History and Exam elements no longer count toward the end E/M code result. The provider’s review of these components should be based on ‘medically necessary and clinically appropriate’ services for the patient’s Chief Complaint and their overall health. EMR Templates will need to be updated in the following ways:

  • History of Present Illness should show the reason for the visit and the interval history.
  • Review of Systems should show the complexity or the lack of it.
  • Past, Family, Social History should show the social determinates of health and exposure.
  • Exam should be documented when performed but should be ‘medically appropriate.’

Choice of Direction

The new guidelines for the E/M level of care code stipulate that the supporting documentation will be in 1 of 2 directions:

1. Use Time as the Key Component.   2. Use MDM as the Key Component.
Time is cumulative on the DOS. Revision to wording and new definitions.
Time includes non-face-to-face services. New scoring of data and complexity.
Revised typical time ranges. ALL office-based encounters.

Time

Beginning in 2021 and except for CPT 99211, time alone may be used to select the appropriate level for office or other outpatient services, regardless of time spent counseling and/or coordination of care. The Documentation Requirements must include a face-to-face encounter with the physician/provider and the total time will now include both the face-to-face [F2F] and non-F2F time personally spent by the physician/provider on the day of the encounter. The total time does not, however, include the time spent by clinical staff. Examples of accepted physician/provider time are: preparing to see the patient, performing a medically necessary exam and/or evaluation, counseling and educating the patient/family, ordering medications, tests, or procedures, referring to and/or communicating with other professionals (when not reported separately), and documenting clinical information. The CPT 99211 is only used when the physician/provider supervises other staff who perform the F2F services.

2021 Time ranges:

99211 minimal
99202 15-29 min 99212 10-19 min
99203 30-44 min 99213 20-29 min
99204 45-59 min 99214 30-39 min
99205 60-74 min 99215 40-54 min

Medical Decision-Making.

The whole concept of ‘additional workup’ has disappeared. Otherwise, the guidelines to describe Medical Decision-Making have only a few changes. They still include the number and complexity of problems addressed at the encounter, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality of the patient management.

The documentation of the problems addressed during the visit should state whether the condition(s) are new, established, acute, chronic, exacerbated, systemic or treatment-based symptoms.

The amount and/or complexity of data to be reviewed and analyzed has changed to form three categories. The first category includes tests, documents, orders, and independent historians. Examples include diagnostic test results from the current provider, communications and/or test results from an external provider, information from a professional who is not in the same group or is a different specialty, or from a caregiver/significant other due to the patient’s condition. It also includes tests for which there is a CPT code and an interpretation is customary, but this does not count toward MDM when the servicing provider is reporting the test separately. Independent interpretations are discussions of management or test interpretation with an external provider or appropriate source. Examples of non-healthcare professionals who may be involved in the management of the patient would be a lawyer, parole officer, case manager, or teacher.

 The risk of complications and/or morbidity or mortality of the patient includes the possible management options selected and those considered, but not selected, after shared assessments and options with the patient and/or family.

Laura Summy is Manager of Coding of MMG Healthcare Solutions / Medic Management Group. MMG is a national provider of consulting services and back office administrative support to independent and system owned physician practice groups.  Additionally, MMG has been formally recognized as a multi-year Northeast Ohio Top Workplaces award winner.

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