E/M office visit historical background

For years, providers have voiced their concerns about the amount of data entry required for Evaluation and Management (E/M) visits.  Many state they spend twice as much time documenting in the Electronic Medical Record (EMR) as they do treating patients.  CMS has sought input from stakeholders on how to accurately report E/M codes without the burdensome reporting guidelines.  
As part of the Centers for Medicare and Medicaid Services (CMS) “Patients over Paperwork” initiative, changes in coding, payment, and documentation requirements for E/M Office or Outpatient Services (99201-99205 and 99211-99215) are being implemented as an effort to reduce administrative burden, increase payment accuracy, and decrease unnecessary documentation in the medical record.  The changes discussed below were finalized in the 2020 Medicare Physician Fee Schedule (MPFS) Final Rule and will be effective beginning January 01, 2021. It is possible that additional changes could be made by CMS in the 2021 MPFS rules prior to implementation. 


      1. Eliminate history and physical as elements for code selection: Starting January 1, 2021, the history and physical examination (exam) elements will no longer be factored into the office/outpatient E/M code selection.    

  • This allows providers to decide how much pertinent history and examination should be documented to allow for a “medically appropriate history and/or examination.”
  • With this change, the healthcare community foresees a decrease in the amount of data within the EMR. 

      2. Providers are allowed to select codes based on Medical Decision Making (MDM) or Total Time: 

  • MDM: The three elements of MDM (complexity of the patient’s presenting problem, data to be reviewed and risk) were not materially changed but did provide edits to the elements for code selection and revised/created numerous clarifying definitions in the E/M guidelines. 
  • Time: The definition of time will change from “typical face-to-face time” to “total time spent on the day of the encounter.” Providers will no longer need to establish how much time was spent in counseling and coordinating care.  Rather, the provider will focus on increments of time spent on the date of the encounter such as preparation for the visit (i.e. reviewing laboratory tests), performance of a medically appropriate examination and orders for medications, tests or other procedures.

      3. Modifications to the criteria for MDM: The current CMS Table of Risk was used as a foundation for designing the revised required elements for MDM. 

  • Removed ambiguous terms (e.g. “mild”) and defined previously ambiguous concepts (e.g. “acute or chronic illness with systemic symptoms”)
  • Also defined important terms, such as “Independent historian”
  • Re-defined the data element to move away from simply adding up tasks to focusing on tasks that affect the management of the patient (e.g. independent interpretation of a test performed by another provider and/or discussion of test interpretation with an external provider)

      4. Deletion of E/M code 99201: E/M code 99201, Office or other outpatient visit for the evaluation and management of a new patient, will be deleted.

  • Eliminated 99201, as 99201 and 99202 are both straightforward MDM and only differentiated by history and exam elements
  • Deleted due to low utilization
  • There are some situations in which a facility may still need to report 99201, for example, those payers such as Workers Compensation that will not immediately adopt the 2021 CPT code changes. 

      5. Creation of a single Prolonged Services code: A shorter prolonged services code that would capture provider time in 15-minute increments. This code would only be reported with 99205 and 99215 and be used when time was the primary basis for code selection.

      6. Creation of a new add-on code for visit complexity: A new add-on code that describes additional resources inherent in visits for a patient’s single, serious, or complex chronic condition.   

Documentation Rules Staying the Same

  • The authentication rules for E/M visits have not changed.  The notes should clearly provide clarity as to whom provided which elements of note or service.  All notes should contain an official electronic authentication from the provider and should be done before billing is performed.  
  • The chief complaint will continue to be required for each E/M visit.  The history and exam have been eliminated for code selection, and only need to be performed and documented for the visit when medically necessary and clinically appropriate.  

Preparing for Change

Consider these helpful tips for best practices for a successful transition:   

  • Create or update existing policies and procedures to align with the coming changes; 
  • Provide timely training and education to practitioners and staff who will be impacted; 
  • Ensure the EMR is equipped with updates to support these changes; 
  • Conduct periodic documentation reviews to monitor compliance;
  • Perform ongoing monitoring efforts post implementation in order to stay compliant.

Preparation for change is essential for success. At Womble Bond Dickinson we can assist in the stages of this transition and beyond.  Please reach out to us if you or your organization has questions, seeks help with implementation, or needs assistance in preparing for change. Please contact lori.baker@wbd-us.com for more information.