The 2021 E/M updates and elements of MDM are continually being clarified. The article below will address questions and answers over the new E/M Office visit guidelines. Read below to see more about the new updates and information. 

By Ginger Avery, CPC, CPMA, CRC
February 2, 2021

Questions and answers continue to be clarified as we are now a month into utilizing the new E/M Office Visit guidelines that took effect on January 1, 2021. Understanding how to navigate labs and other test results as they pertain to the time and medical decision-making (MDM) elements of the revamped E/M office visit rules can be hard to ascertain. The following details should help improve understanding of the new data review rules. 

Data Element:

  • When tests are ordered during one visit and reviewed the same test during the next visit, can that count as a data point for both visits?
    No. When a clinician orders a test during an E/M visit, the order and review of the test result will count toward the MDM of the first encounter.
  • If we receive a test result two days after the visit, can we count a data point toward that E/M visit for review of the test?
    Yes, there’s pre-service work and post-service work associated with the encounter and receiving a test result a couple of days later and responding to it are part of the post-service work of the encounter.
  • Can the independent visualization of a test be counted in the medical decision making if the physician is also billing for the test?
    Per AMA, the actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the level of E/M service when reported separately. Clinician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The clinician’s interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service but is not separately reported; it is part of medical decision making.
  • If one doctor orders a test that is performed in the practice, but a second doctor bills for the test, can the first doctor count the test order toward MDM for his visit?
    Practices should not count a test toward MDM if the ordering practitioner’s practice also performed and billed for the test. Medicare and private payers could view that type of coding as abusive or fraudulent.

Documentation Questions:

  • Since history and physical exam are no longer required to level the visit, should these elements still be documented?
    Yes, history and exam are still part of an evaluation. The documented content should be focused only on the clinically relevant details and cognitive thoughts of the clinician. Document the nature of the presenting illness(es) (subject details with pertinent ROS). Document a medically necessary exam. Documentation is about the quality of the story, not the quantity of details. Avoid importing pages of past medical history, ROS or medication lists that are note relevant or helpful. Clinicians are encouraged to write clear stories that they would like to read.
  • Do I still have to document ROS and PFSH?
    Yes, when clinically relevant. For example: Patient presents with chest pain. Has been having intermittent chest pain at rest for two weeks. No notable triggers. Positive for headaches and dizziness, no SOB. Patient has a family history of CAD. Remember, documentation is all about the medically necessary story.
  • When coding based on total time does the assessment and plan still need to be documented?
    Yes. Quality documentation should always be captured. Clear stories that include clinical impressions and plans support the medical necessity and describe the complexity for the services provided, regardless of how you choose to report the visit.

Other Common Questions:

  • Are commercial plans required to adopt the revisions to E/M codes?
    Yes. The CPT code set, together with the U.S. Department of Health and Human Services’ Healthcare Common Procedure Coding System, has been adopted as the nation’s standard medical data code set. HIPAA requires that health plans use the most recent version of the medical data code set, they should have implemented these revisions Jan. 1, 2021.
  • Do the 2021 E/M code and guideline changes apply to all categories of E/M services?
    No. The E/M code and guideline changes are specific for office and other outpatient visits and apply only to codes 99201–99205 and 99211–99215. Inpatient services still need to follow the key component guidelines (1995 or 1997).
  • When considering High-Risk MDM, there is an example listed: “drug therapy requiring intensive monitoring for toxicity”. What constitutes supporting this definition? When considering this complexity, both the drug and the monitoring must qualify. The new guidelines provide this definition when considering this High-Risk example:
    “Drug therapy requiring intensive monitoring (today) for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Both the drug and the monitoring must qualify on the date of the encounter.
  • Where can the CPT E/M code and guidelines be found?
    The CPT E/M code and guideline changes for 2021 can not only be found on the American Medical Associations’ (AMA) site at this link. They can also be found in their entirety within the 2021 CPT Code books themselves. These guidelines include details about reporting based on the total encounter time, the new level of medical decision-making table and the 22 new definitions that help clarify what the MDM terms mean. 

As a reminder, documentation is about painting a clear picture of each encounter. The power of storytelling is evident with these new updates. Quality documentation provides details to support and defend the medical necessity and appropriate complexity of each unique encounter, as well as improves overall patient care and clinical outcomes. Due to President Biden recently issuing several health care executive orders, we can expect policy adjustments that will lead federal auditors and investigators to focus on subjects like: fraud and abuse (especially in the telehealth arena), auditing of provider relief funds received during the PHE, HIPPA compliance, meaningful use, workplace safety and Evaluation and Management (EM) services. With increased emphasis on these interrelated topics, clinicians are encouraged to focus documentation efforts on the cognitive clinically relevant details, regardless of the clinical setting. Document what you do, code what you document. Consider an educational audit review for your clinicians to see if they are taking proper credit for all the work they do by telling great stories in their encounter notes.

Keep an eye out for more guidance from Medicare and private payers. Currently, Medicare is still working on an update to its documentation guidelines for E/M services.RT Welter provides robust coding and documentation training for these updates, as well as other topics. Please contact to book your training now.

AMA CPT® E/M Code and Guideline Changes for 2021
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Noridian E/M Documentation Requirements
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