Focus on Evaluation and Management Services: New blog series

Oct. 16, 2020 / By Colleen Ejak, RHIA

For much of 2020, HIM and CDI professionals have been focused on COVID-19 and understanding how the temporary waivers for medical care delivery and payment impact documentation and coding. We are now into mid-October and 2021 will be here before we know it. 

As my fellow blogger Rebecca Caux-Harry discussed in her recent blog, big changes are coming to coding, documentation and payment for Evaluation and Management (E/M) services. To help you understand and prepare, a team of 3M coding experts will blog about different components of the changes in detail over the coming weeks as we prepare for the effective date of January 1, 2021.

Not all E/M categories are impacted by the 2021 changes, but two significant categories are: Office and Other Outpatient Services for New and Established patients. These two categories are significant because they represent approximately 60 percent of all E/M services submitted to Medicare for payment. This means any provider who sees patients in a clinic or office setting will be impacted by these changes. 

It’s been a long time since the E/M guidelines were implemented. We currently have two sets of guidelines in place, the 1995 E/M guidelines and the 1997 E/M guidelines. If you do the math, that means the current guidelines have been in place for 25 years! So much has changed is 25 years: electronic medical records, quality initiatives and value-based care to name a few.

The changes being implemented on January 1, 2021 are the result of a collaborative effort between the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), with the goal of reducing administrative burden and giving providers more time with their patients.  

So, what changes did the AMA make and CMS adopt into Medicare Physician Fee Schedule Final Rule for these two E/M categories?

• The history and physical exam are no longer components for E/M level selection
• The level of service will be based on Medical decision making or total time
• Time was revised to be total time spent on the day of the encounter not just face-to-face time
• Counseling and/or coordination of care do not need to dominate the visit for time to be the basis for level selection
• The medical decision making criteria has extensive revisions, revisions that are more clinically intuitive
• A new prolonged services E/M code was created to capture provider time in 15-minute increments. The code will be used with 99205 and 99215 when time is the basis for code selection
• 99201 – level 1 new patient will be deleted, all 5 levels of services for established patients are retained

Stay tuned for our E/M blog series to learn about the changes that will impact you. We’ll spend some time discussing the new definitions such as the independent historian, better defined clinical terms such as stable chronic problem, a look at the new and existing prolonged services E/M codes and the impact of including social determinants of health in the E/M level selection. Until next time have an awesome autumn, a Happy Halloween and most of all, stay safe!

Colleen Deighan, RHIA, CCS, CCDS-O, is a consultant with 3M Health Information Systems.

Learn more about the 2021 E/M changes.