Beyond Coding & Documentation: The Impact of the 2021 E/M Changes

2020 was a momentous time in healthcare - for many reasons. Last year, the landscape of healthcare changed significantly as we adapted to telehealth services as a routine vehicle for providing healthcare because of COVID-19. Additionally, many organizations transitioned their workforce to remote work environments. Amid those changes, for the first time in nearly 25 years, new evaluation and management guidelines have been implemented effective January 2021. Since then, AAPC Services’ efforts have been largely focused on education, training, and auditing organizations’ success on the implementation of the new guidelines.

In this eBrief, part one of our ongoing series, we will discuss the impact of the 2021 E/M guidelines changes. But first, let’s revisit how we arrived here after nearly 25 years of using the 95 or 97 E/M guidelines.

The Patients Over Paperwork Initiative was launched by CMS Administrator Seema Verma with the goal of cutting the red tape of burdensome regulations, while increasing the efficiency and improving the patient experience, all in an effort to make healthcare more patient centric. A study published in the Annals of Internal Medicine reported that primary care physicians spend 27% of their time on clinical services and 49% of their time on administrative functions. That 49% of time on administrative functions is adversely affecting clinicians and contributing to physician burn-out.

There are different components to the Patients Over Paperwork Initiative, but in this eBrief series we will focus on revisions to the E/M guidelines. The goal of the Patients Over Paperwork Initiative was to reduce the administrative burden for practitioners, allowing them to focus more on the patient and less on paperwork. This was meant to be achieved by reducing documentation requirements such as HPI elements, ROS, or past family social history. Practitioners’ primary focus should be clinical care of the patient. The goal is to move away from the box-checking methodology of leveling an office visit, and direct more focus on medical decision making.

The 2021 E/M guidelines eliminate history and exam as required elements of leveling a visit. With the new guidelines, clinicians now only need to document a clinically relevant history and exam. Code selection is now based on medical decision making or total time spent on the day of the visit. For the last year, the healthcare industry has focused largely on educating providers, billers, coders, and auditors with the “how” part of implementation of the guideline changes. In an article published by MGMA in October of 2020, 47% of Healthcare leaders say their practice was prepared at the time. Which leaves 53% of organizations only a few months ago who considered themselves unprepared.

The American Medical Association published an article called “10 Tips to Prepare Your Practice for E/M Office Visit Changes.” The article gave some very practical information on how organizations can plan for the operational, infrastructural, and administrative workflow adjustments that will result from these changes. What is the impact of these guideline changes beyond coding and documentation?

EHR / RCM System Preparedness

Beyond coding and documentation, one of the areas impacted by the 2021 E/M guidelines is Electronic Health Record (EHR) and/or Revenue Cycle Management (RCM) system preparedness. With the landscape of provider documentation requirements changing along with the addition of new CPT codes, the deletion of 99201, new time parameters, and the change in leveling criteria for existing office outpatient CPT codes, system optimization becomes crucial. The American Medical Association (AMA) worked very closely with EHR Vendors and other stakeholders leading up to these changes. CMS also announced in the final rule that they would adopt the AMA CPT code changes with some exceptions.

Additionally, commercial payers are required to adopt the E/M office visit code revisions. The CPT code set has been adopted as the standard medical data code set for physician services. The 2021 E/M guideline updates are now part of the CPT code set. Health plans are required by HIPAA to use the most recent version of the medical data code set.

Payors, to whom services are submitted for reimbursement, are adopting the 2021 E/M code revisions, so we can expect that EHR and RCM vendors are adopting the CPT codes set as well. There are both additions to, and deletions from, the code sets that are affected by the guideline changes, as well as significant changes in time ranges. It is imperative that your EHR is updated with the most current code sets to ensure both accurate reporting and reimbursement of services.

Many EHR’s use automatic coding applications within the system to make recommended code assignments. Changes in logic within these applications are necessary since the history and exam are no longer key elements used in code selection. Additionally, the data is calculated very differently and there are no longer designations of new or established problems with or without workup. Ultimately, correct code selection corresponding to the medical record documentation should be reported regardless of whether changes have been made in coding logic.

Provider documentation templates will also need to be updated. Outpatient office visit E/M code selection in 2021 is based on either total time spent or medical decision making. Providers no longer need to worry about documenting a certain number of elements of HPI, review of systems, past family social history or a certain level of exam for code selection, this is not to imply that these elements do not have to be documented, but documentation now defers to what the provider deems clinically relevant. In addition, the guidelines specify changes in time parameters for the outpatient office visit code sets. Provider templates updated with the new time parameters along with specification on how that time is spent will guide providers in accurate documentation and reduce missed opportunities for reimbursement.

auditing-focused woman at comp

Organizations that perform other E/M services (e.g., consultations or inpatient evaluation and management services) need to bear in mind that they will be using the 95/97 guidelines for those services. Can your EHR accommodate all the services your organization provides with the applicable guidelines? Even though the history and exam are not required elements when leveling an outpatient E/M services in 2021, a clinically relevant history and exam is necessary, and the information provided is still used to arrive at the correct code selection, so these elements cannot be skipped in the documentation.

Coders and auditors frequently use information from the whole note to arrive at the MDM level.

For example:

  • What is the patient’s current smoking status?
  • What are the patient’s comorbidities?
  • What medications is the patient taking?
  • Are there social determinants that affect the patients’ access to care or health status?

This information ultimately aids a coder or auditor in deciding a patients’ level of risk. It is important that provider templates reflect the new guideline changes but do not hinder accurate code selection either.

Claim edits is another area likely to be affected by the new guidelines. Both 
claim edits and provider templates are affected by the new prolonged service codes. CMS did not adopt the AMA’s prolonged service time recommendation, so we have not only two different codes for prolonged services, but two different time applications when it is used. It is recommended that your EHR recognize both payor and time to ensure accurate code selection for prolonged services.

EHR / RCM systems frequently have claim edits for payor guidelines related to consultations. As a result of the 2021 guidelines changes, consultations can no longer be crosswalked to outpatient E/M codes.

Diagnosis code specificity is also an area of importance that may be affected by claim edits. With medical decision making now being one of the two driving leveling forces for office outpatient visits, accurate and specific diagnosis code selection is extremely important. There is a difference between an “acute, uncomplicated” versus an “acute, complicated” diagnosis, or a “stable chronic illness” versus an “exacerbation of a chronic illness.” For example, the difference between unspecified chronic obstructive pulmonary disease and an acute exacerbation of chronic obstructive pulmonary disease or an unspecified concussion versus concussion with loss of consciousness is often the difference between a low and moderate nature of presenting problem.

When auditing services, we commonly see organizations not include each diagnosis code that affects a patient’s care on the date of service. Using the correct diagnosis code(s) communicates the clearest picture of medical necessity to payors, which may remove potential claim denials or pre-payment requests for medical records.

Hopefully, at this stage, your EHR / RCM vendor has made system updates and provided you with details of those updates. Payors will need to ensure their system is also prepared. It is anticipated to see discrepancies for quite some time between provider organizations and payors being at varying levels of readiness. For this reason, we strongly recommend review of codes prior to claim submission ensure accuracy and close monitoring of claim denials and reimbursement.

That’s it for Part 1 of our new series, “2021 E/M Changes: The Impact Beyond Coding & Documentation.” Stay tuned for next week when I’ll turn my focus to the impact on Revenue Cycle Management. In the meantime, if your organization could use help adapting to the 2021 changes, you can learn more about our services here.


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