Looming 2021 E&M Changes Won’t be an Excuse to Start Skipping Documentation

Original story posted on: September 7, 2020

The 2021 evaluation and management (E&M) changes are definitely happening. We’ve seen the Medicare Physician Fee Schedule proposed rule for next year, and there’s no provision there to delay or cancel them.

To recap, for office/outpatient E&M codes 99202-99215 – remember that 99201 will be deleted – CPT® is removing the key components of history and exam as factors in determining the E&M level. Instead, it’s going to be either medical decision-making (MDM) or total time spent. Remember, “time spent” in 2021 will include not just face-to-face time, but also non-face-to-face time spent on the same date of service, including time spent on tasks such as preparing for the visit, care coordination, and so forth. The new rules also eliminate the requirement that a majority of the time must be counseling-oriented.

Now, I got to ask the Centers for Medicare & Medicaid Services (CMS) some questions on a recent open door call, and their responses should throw a little cold water on the idea that the new rules are a green light to start skipping big chunks of E&M documentation.

First, there’s a lot of hype surrounding the elimination of the history and physical exam as key components. But you can’t just ignore them next year, because the new rules say that a “medically appropriate” history and exam must be documented, and CMS agrees that this phrase is the new bar. In the words of Ann Marshall, CMS technical advisor, and I quote: “but the code descriptor right now just says … ‘history and exam as medically appropriate.’ So that would be the bar that you would need to meet. So if you didn’t include a history and an exam, I would think that an auditor would just be looking at the medical record. And if you could show (or) demonstrate from any of the material and the record … that they were not medically necessary, then that would be okay. But I can’t tell you how … that individual decision would be made, and it’s probably on a case-by-case basis.”

Now, I can tell you that whenever CMS says something is on a case-by-case basis, you have got a solid case for being cautious, in terms of compliance. E&M notes still need to demonstrate medical necessity, and there’s a risk that having minimal history and exam could detract from the medical necessity picture.

Second, some folks believe that the elevation of time as a decisive factor means that you can throw the rest of the guidelines out the window whenever you document the time spent. But CMS says that medical necessity rules still apply. Again, from Ms. Marshall of CMS, I quote: “Medicare law does have some general language saying that all of the services that are paid for need to be medically reasonable and necessary. So I think that is not something that we can just sort of dispense with, in terms of judging whether time was needed or not. And I think that we will also probably have further conversations as this goes – as this was implemented with the auditing folks on how they’re going to look at time and think about (it). So I think that generally, anything that you bill for needs to meet medical necessity and have met that bar. But exactly how that’s going to play into individual cases and documentation, … we don’t know yet.”

So simply documenting time may not save an otherwise skimpy note that’s being billed as a 99205. Time is not going to be a silver bullet in 2021, and if I were a betting man, I’d put my money on time-based E&M documentation suddenly emerging as a top U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) target in 2022. The bottom line is that the new rules are not a license to go wild with documentation shortcuts.


Grant Huang, CPC, CPMA

Grant Huang, CPC, CPMA is director of content for DoctorsManagement.

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