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What’s new with E/M coding? This chart can help you remember
The most consequential changes to office/outpatient evaluation and management (E/M) coding in more than two decades took effect Jan. 1. Physicians and other qualified health professionals will now be able to level visits based solely on either medical decision making (MDM) or total time. The ways MDM and total time are calculated have changed somewhat, and will probably take some getting used to, but the good news is that the supporting documentation burden should be lower. Here’s a chart that can help you quickly remember what’s new this year compared with last year:
| YEAR | CODING WITH MEDICAL DECiSION MAKING | CODING WITH TIME | HISTORY & EXAM |
|---|---|---|---|
| 2021 | • Number and complexity of problems addressed • Amount and/or complexity of data to be reviewed and analyzed • Risk of complications and/or morbidity or mortality |
• Total time (including non-face-to-face time) on date of visit; can be used for any visit |
• Only required as medically appropriate and not part of code level selection |
| 2020 | • 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 used when counseling and/or coordination of care dominate encounter |
• Key elements in selection of level of service |
For more on the coding changes, see the following FPM articles:
- “Countdown to the E/M Coding Changes,”
- “The 2021 Office Visit Coding Changes: Putting the Pieces Together.”
Watch for an article on coding level 4 visits, specifically, in the upcoming January/February issue of FPM.
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