• AAFP Fields New Resource on Coding, Documentation Changes

    2021 Office Visit E/M Guidelines Module Details the Revisions

    January 27, 2021, 9:36 am News Staff ― With all the unwelcome challenges 2020 brought, it’s nice to know that this new year promises to bring positive changes. Case in point: revised office visit evaluation and management coding and documentation guidelines that took effect on Jan. 1.

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    Designed to cut administrative burden and boost the amount of time physicians can spend caring for patients, the new guidance prompts family physicians to shift their thinking when it comes to documenting and coding for the services they most commonly provide.

    To support FPs in transitioning to the new system, the AAFP has compiled a comprehensive collection of information, resources and tools on E/M coding. The most recent such resource, available exclusively to Academy members, is the 2021 Office Visit E/M Guidelines Module.

    As a reminder, here’s a recap of the key changes for 2021:

    • for new patients, the number of levels of office visit E/M services dropped from five to four (CPT codes 99202-99205);
    • five levels have been retained for established patients (CPT codes 99211-99215);
    • physicians can select the appropriate level of office visit based on either medical decision-making or total time spent by the physician or other treating clinician ― both face-to-face and non-face-to-face ― on the date of service; and
    • time and MDM methodologies have been revised for all office visit E/M codes, and history-taking and exams are required only when medically appropriate.

    The new module walks members through the revised guidelines and provides a detailed understanding of how to apply them.

    Regarding code selection by total time, for example, the module offers an in-depth look at how to code for and document prolonged services, whether rendered on the date of a face-to-face patient encounter or on a date other than the date of a face-to-face visit.

    Similarly, the module highlights and defines key terms in the context of documenting the amount and/or complexity of data to be reviewed and analyzed when selecting codes based on MDM, such as information provided by independent historians on patients’ behalf and specific social determinants of health that should be explored.

    The first installment in the Family Medicine Practice Hacks video series is also featured on the Academy’s E/M coding webpage. In the video, AAFP Manager of Practice and Payment Erin Solis highlights various coding-related resources the Academy has developed, including checklists to help solo and independent practice physicians, as well as employed physicians, ensure they have all the information they need to function smoothly in the new coding environment.

    Among other useful tools available from the AAFP, new coding and documentation reference cards stand out as a handy way for physicians, family medicine residents and nonphysician practice team members to track and utilize important coding information. Order your cards today.

    And for family physicians looking for additional information about the 2021 E/M coding changes, the January/February 2021 issue of the Academy's premier practice management journal, FPM, offers members and subscribers several features examining this topic. One particular article presents a comprehensive breakdown of factors to consider when deciding whether a given visit should be coded as level 4 versus level 3.