Focus on E/M coding: New Year, new resolutions, new outpatient office visit coding guidelines

Jan. 25, 2021 / By Karla VonEschen, MS, CPC, CPMA

New year, new month, new changes to documentation and coding for outpatient office visit codes 99202-99205 and 99211-99215. If it feels like you have been inundated with information and updates about the 2021 Evaluation and Management (E/M) changes for outpatient office visits, you are not alone. Let’s be honest, it can be overwhelming and even annoying, but understanding and preparing for the changes will pave the way for success. We have heard about these changes nonstop for the better part of two years and as of January 1 they are a reality. So, now that you have done a gap analysis, educated your coders and physicians and updated your templates for the new year, what’s next? Post-implementation auditing!

Medical Decision Making or Time are now used for the assignment of outpatient office visit E/M codes and the patient history and exam are no longer factors. However, this does not mean physicians should be less concerned with how they document. After all, medical necessity is still the overarching standard on which payment for office visits is based. Here are some considerations when performing an audit of the new E/M changes:

• Prior to starting any audits, make sure all internal compliance plans and audit policies have been updated with the new outpatient office visit 2021 guidelines in mind.
• Don’t wait too long before auditing physician documentation. It’s critical to make note of issues early on and provide staff with appropriate education to correct issues.
• Since this change is new for everyone, review notes for both new and current physicians at your practice.
• Pull a good sample of notes from each E/M level for review (99202-99205 and 99211-99215).
• History and exam no longer require a certain number of bullets, but providers should clearly document the patient’s condition in the history and an examination of clinically relevant areas at each encounter.
• Verify physicians continue to clearly show medical necessity in documentation.
• Watch for trends where physicians become dependent on use of time. When physicians use time, their documentation must support time spent with the patient. For example, you wouldn’t expect to see a 45-minute visit for an otherwise healthy patient being seen for acne.
• When reviewing documentation for time, verify physicians are consistently documenting total time for the encounter.
• Medical decision making is determined based on two out of three MDM elements documented. These should be clearly stated in the physician Impression or Assessment and Plan.  The AMA has a great resource for Medical Decision Making leveling: CPT Outpatient E/M Office Visit and Other Services Code and Guideline Changes

Once your initial baseline audit is complete, follow up with your physicians as soon as possible and educate them on the findings. The earlier you communicate documentation issues with staff, the easier it will be to effect changes. Follow up audits are recommended to revisit any trending issues identified during the base audit. Verifying that previous documentation issues have been addressed is critical for compliant and accurate coding. 

As you dive into 2021 with new resolutions and resolve, I recommend you add in the goal of making sure your physicians have good documentation habits to support the new outpatient office visit coding guidelines.

Karla Voneschen is a coding analyst at 3M Health Information Systems.

Learn more about the 2021 E/M changes.