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2021 E/M Changes Are Here…Time to Change

It is important to note that this did not sneak up on us or even change from the proposals. However, there will be many disappointed practices and providers who are not ready for the changes on January 1, 2021. Understanding the expectations of the new E/M requirements is key to ensuring proper and timely payment. There is also no doubt that auditors will be reviewing the documentation of these codes over the next year and recouping monies for unsupported/unclear claims that are submitted.

The impact is for codes 99201-99215.

  • Code 99201 has been eliminated for 2021
  • Code level set will be based on Time or MDM

Documenting Based on Time:

All time spent on patient related visit can be counted toward level on same DOS

  • Reviewing tests – pre patient visit
  • Obtaining / reviewing outside history and relevant information for visit
  • Performing medically appropriate examination
  • Counseling and education for patient, family, or caregiver
  • Time spent ordering- Tests, Lab, or other procedures
  • Communicating or referring to/with other healthcare professionals
  • Time spent entering information into EMR/EHR
  • Interpreting test results
  • Coordinating care for patient

Internally you need to:

  • Educate providers and those involved with coding
  • Update your compliance plans
  • Create post education review and “Cliff Note” reference for staff/providers
  • Contact ALL payers and see how and what their requirements will be
  • Revise templates to reflect changes if used
  • Update practice procedures and protocols
  • Increase the amount and frequency of audits of these codes to ensure accuracy

Documenting Time:

I do not recommend simply documenting a total time. Best practice recommendation, especially knowing how these codes will be the focus of audits, would be to document time per element/task and then totaling


  • You should still be documenting/capturing pertinent patient history and Relevant physical exam elements