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Key Takeaways from 2021 E/M Code Changes

Thursday, September 10, 2020 9:00 AM

Hot Topics, Billing, Coding & Compliance

Written by: Kirk Mack

Kirk Mack
Senior Consultant

The Centers for Medicare & Medicaid Services’ (CMS) Patients Over Paperwork initiative is prompting some significant changes to Evaluation and Management (E/M) coding of outpatient office visits that are due to take effect soon — Jan. 1, 2021, to be exact. Ideally, by now, the practice will have designated a project lead or point person to coordinate the associated documentation changes and will be educating the rest of the team on these E/M code updates, which may in turn necessitate revisions to practice protocols, workflows, policies, and procedures.

When educating staff on these fast-approaching code changes, it is important to make sure that staff understand the overarching intent and nature of these changes to better foster buy-in and compliance.

Important Callouts

To aid in that education, below are four major takeaways to call out to staff. While the upcoming E/M code changes are sweeping — as evident by the wide-ranging callouts below — many are anticipated to ultimately benefit practices. Let us explore how in more detail.

Reduced documentation requirements. Currently, E/M codes are determined by either physician-patient face-to-face time or tabulating history, exam, and medical decision-making (MDM). The tabulation process generally wastes time by obliging providers to repeat aspects of history and exam. Acknowledging that, the upcoming 2021 E/M code changes center on allowing providers to focus on patient care and less time performing redundant tasks. How that is intended to be achieved is through the following changes:  

  1. Deleting new patient E/M code 99201.

  2. Having E/M codes 99202 – 99215 determined by either MDM or the physician’s time to complete the entire visit. Physician time will include more than just face-to-face time with the patient.

  3. Eliminating the many required elements for exam and history (e.g., history of present illness, review of systems, and past family and social history) to determine the proper code. However, an appropriate history and exam, specific to the patient and relevant to the conditions, should be documented. For example, a physician would not need to document the cornea when evaluating or treating a retinal condition as it is not relevant to the condition. Meanwhile, the chief complaint, which provides medical necessity for an office visit, will remain a necessary documentation element. 


New add-on codes. There are revisions to the prolonged services add-on codes, which can only be used when time is the basis for E/M code selection. Meanwhile, Medicare is adding a visit “complexity” code that is not related to provider or staff time. Knowing this, the practice should keep the following considerations in mind:

  1. Codes for significant staff time exceeding a threshold may be billed when the physician uses time for E/M selection.

  2. Prolonged services codes for provider time may be used for extensive provider time.

  3. CMS is proposing an add-on code, GPC1X, for visit complexity.

E/M reimbursement changes. Within the proposed 2021 Physician Fee Schedule (PFS), the budget neutrality requirement has caused the 2021 conversion factor to decrease by 10.61 percent. The current conversion factor for 2020 is $36.09 and the proposed change reduces the conversion factor to $32.26 in 2021. CMS estimates a negative impact for ophthalmology and optometry of 6 percent and 5 percent, respectively. However, the work relative value units (RVUs) for E/M codes, specifically the established outpatient E/M codes (99212 – 99215), show proposed increases ranging from 14 to 30 percent.

*Correction: Earlier on Sept. 10, 2020, this post incorrectly stated the decrease to the proposed 2021 conversion factor. It has since been corrected. BSM regrets the error.


Telemedicine changes. Due to the pandemic the entire health care industry is currently benefiting from the relaxed requirements for telemedicine services. However, CMS announced in the 2021 Proposed Rule that it will no longer recognize the outpatient E/M office visit codes (99202 – 99215) for telemedicine services at the conclusion of the COVID-19 public health emergency.

Use This Time Wisely

Further clarity on these changes is expected to be in the Final Rule, scheduled for release in December. That release is later than normal likely because CMS did not publish the Proposed Rule until last month due to COVID. Use this delay to review the 2021 Proposed Rule and submit comments on any of the expected changes or updates. As for the E/M requirements with respect to MDM and time, they appear to be mostly finalized; therefore, now is also a great time to continue preparing the practice team to carry out a seamless transition at the start of the new year.

ADDITIONAL RESOURCE: BSM will be holding live webinars on 2021 E/M code changes, starting Sept. 16. Register today to join a session.

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