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New E/M Documentation Guidelines, Table Take Effect Soon; 'There Is a Different Mindset'

A switch will soon be flipped on coding and documentation for office and other outpatient visits, with new guidelines[1] that take effect Jan. 1 for Medicare and private payers. Physicians and other clinicians will base their evaluation and management (E/M) levels of service on the documentation of time or medical decision-making only, with new definitions of both, so they don’t have to factor in the history and exam, although they still must be medically appropriate. With the clock ticking, it’s a good time to prepare, especially if providers are not swamped with COVID-19 patients, experts say.

CMS in the 2020 Medicare Physician Fee Schedule regulation “aligned” E/M coding with changes adopted by the American Medical Association (AMA) CPT Editorial Panel for office/outpatient visits, with a 2021 effective date. “Instead of the 1995 and 1997 Medicare documentation guidelines, we are going to be using a new set of guidelines for office and outpatient codes,” said Valerie Rock, a principal with PYA in Atlanta, Georgia. The AMA documentation guidelines are baked into the CPT codes, which implies they apply to all payers, and CMS has embraced them. The E/M guidelines were created by the AMA and incorporated into the CPT manual, which is a departure from the past, when payers adopted the 1995 and 1997 guidelines.

The changes affect nine CPT codes: four for new patients (CPT 99202-99205)—99201 has been deleted—and five CPT codes for established patients (99211-99215).

“Technically, providers are going to be documenting as was always intended by the guidelines—documenting what’s pertinent in the medical record, that communicates to you when you see the patient again and to your colleague who may see the patient later” and, in theory, for malpractice protections in the event of a lawsuit, Rock said. “Now there will not be this feeling that ‘I have to do four HPI and 10 reviews of systems and three past, family, and social histories; eight organ systems; and medical decision-making.’ Now it’s less structured.”

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