Practicefirst would like to remind its clients of the 2021 E&M changes that are applicable ONLY to the office/outpatient code set. These changes will be effective January 01, 2021. A few documentation recommendations for 2021 are as follows:

  • Medical necessity was and remains the overarching criteria in selecting a level of service.

  • History and exam documentation should be medically appropriate and is at the discretion of the provider but will no longer be used for scoring an E&M visit.

  • Office/outpatient E&M visits will be scored based on medical decision making (MDM) or time.

  • The documentation should focus on a robust MDM. A robust MDM should tell the story of how sick the patient truly is and support the medical necessity of the level being billed.

A robust MDM should contain but is not limited to the following:

  • Details of all the tests ordered, reviewed, and analyzed.

  • Independent interpretation of tests when performed.

  • Discussions with individuals other than the patient (eg. specialists, PCP, case workers, guardians, independent historians, family etc).

  • Differential diagnosis considered and the work up ordered to rule out or confirm these diagnoses.

  • The status (stable, not at goal, exacerbated, worsening) of the chronic conditions addressed at the encounter.

  • Care plan for each of the conditions being addressed.

  • Co-morbidities/underlying conditions that have an impact on the treatment plan of the current condition.

  • Risk associated with the conditions being addressed.

  • Prescription management.

  • Risks associated with minor/major surgeries.

  • Any treatment or testing that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian choice.

  • When time is used to score an E&M, it includes the time spent by the provider (Clinical staff time should NOT be included) on the date of service. Please refer to the CPT book to see the list of all the activities that contribute to the total time of the visit.

  • A new prolonged visit code (99417) has been added in the CPT book for 2021. Medicare will not recognize the 99417 and is introducing the code G2212 for 2021 prolonged visits.

This is not an exhaustive list and we encourage our clients to read the guidelines published in the CPT 2021 book.

For Coding questions, please contact our Coding Managers, Vidya Baliga at vidyab@pracfirst.com and Kelly Cole at kellyc@pracfirst.com or at 716-389-3262.