E/M Changes Generated in March 2021 for January 2021

By Shawntea (Taya) Moheiser, CMPE, CMOM, EMBA

We had to wait so this wasn’t posted on April Fool’s day, but we almost didn’t believe it ourselves. More E/M documentation changes, but with a spring surprise… these changes are retroactive to January 1, 2021.

Maybe you’re already groaning but maybe you’re just hearing this now, either way it’s pertinent information so who are we to keep it to ourselves?

Notable Changes

1. Time Counting Exclusions – You may not count time:
   1. When performing other services that may be reported separately
   2. For travel time, or
   3. For general teaching discussions with your Care Team that are not required for the management of a specific patient.
2. Services Reported Separately
   1. The ordering, performance, and/or interpretation of diagnostic test/studies during a patient encounter are not included in determining the E/M level in certain circumstances (example: when tests are reported separately unless those tests do not require separate interpretation)
3. Revisions to Medical Decision Making and Documentation – The following revisions were issued:
   1. Presenting symptoms that are likely to indicate a highly morbid condition may drive MDM even when the ultimate diagnosis is not highly morbid.
   2. For the purposes of data reviewed and analyzed, pulse oximetry is not considered a test.
   3. Data received is not the subject of the analysis, instead, the data should be used in the overall thought process and analysis
   4. The term “discussion” in coding indicates that an interactive communication was held. In addition, though communication may be asynchronous, like portal messages, it must be direct from provider to patient not through clinical support staff.
   5. Selecting the risk of complications and morbidities is distinct from the risks inherent to the condition itself.
   6. Surgical categories (minor/major, elective/emergency, and risk-factors/patient/procedure) each contain greater definition.
   7. Ordering a test may include tests that were not performed

You’ve done so much the last twelve months that already that it’s tough to ask for more, but it is pivotal that you have a clear understanding of the changes that took place. Therefore, it is highly recommended that you read through the entire CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes document issued by the American Medical Association available on their website.