The 2021 Office Visit Coding Changes: Putting the Pieces Together
Simplified guidelines for coding and documenting evaluation and management office visits are coming next year. Learn how to apply the guidelines to some common visit types.
Fam Pract Manag. 2020 Nov-Dec;27(6):6-11.
Author disclosures: no relevant financial affiliations disclosed.
Editor's note: In its 2021 Medicare Physician Fee Schedule, CMS released new guidance regarding coding for prolonged E/M services. This article has been updated accordingly.
The American Medical Association (AMA) has established new coding and documentation guidelines for office visit/outpatient evaluation and management (E/M) services, effective Jan. 1, 2021. The changes are designed to simplify code selection and allow physicians to spend less time documenting and more time caring for patients. Physicians and other qualified health professionals (QHPs) will be able to select the level of office visit using either medical decision making (MDM) alone or total time (excluding staff time) on the date of service. In addition, the history and physical exam will be eliminated as components of code selection, and code 99201 will be deleted (code 99211 will not change). (See “E/M coding changes summary.”)
To follow up on the previous FPM article detailing these changes (see “Countdown to the E/M Coding Changes,” FPM, September/October 2020), we have applied the 2021 guidelines to some common types of family medicine visits, and we explain below how documentation using a typical SOAP (Subjective, Objective, Assessment, and Plan) note can support the chosen level of service.
In each vignette, we've arrived at a code based only on the documentation included in the note. It's possible that a more extensive note could support a higher level of service by further clarifying the physician's decision making. But we've analyzed each case through an auditor's lens and tried not to make any assumptions that aren't explicitly supported by the note.
Starting in January, physicians and other qualified health professionals will be able to select the level of office visit using either medical decision making alone or total time (excluding staff time) on the date of service.
Medical decision making is made up of three factors: problems addressed, data reviewed, and the patient's risk. The highest level reached by at least two out of three determines the overall level of the office visit.
If the visit was time-consuming, but the medical decision making did not rise to a high level, the physician or qualified health professional may want to code based on total time instead.
E/M CODING CHANGES SUMMARY
Coding for outpatient and office visit evaluation and management services will change starting Jan. 1, 2021. Here's a brief summary of how the new guidelines will differ from the current guidelines.
|Year||Coding with medical decision making (MDM)||Coding with time||History and exam|
Number of diagnoses or management options
Amount and/or complexity of data to be reviewed
Risk of complications and/or morbidity or mortality
Typical time face-to-face; only when counseling and/or coordination of care dominate encounter
Key elements in selection of level of service
Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions
More in FPM
Related Topic Searches
MOST RECENT ISSUE
Access the latest issue
of FPM journal