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.

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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.

YearCoding with medical decision making (MDM)Coding with timeHistory 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


show all author info

Carol Self is a former coding and compliance strategist at the American Academy of Family Physicians (AAFP) in Leawood, Kan....

Kent Moore is senior strategist for physician payment at the AAFP.

Dr. Church is a family physician practicing rural medicine in Hiawassee, Ga. He is core faculty for the Northeast Georgia Medical Center Family Medicine residency program and an AAFP adviser to the American Medical Association's CPT Editorial Panel.

Author disclosures: no relevant financial affiliations disclosed.


Copyright © 2020 by the American Academy of Family Physicians.
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