Updated on: March 26, 2019

Revisions on the Horizon for E&M in 2021

Original story posted on: March 25, 2019

AMA is on track to revise E&M codes, set new documentation guidelines.

The American Medical Association’s (AMA’s) CPT® Editorial Panel has approved many changes to the evaluation and management (E&M) documentation and coding guidelines. If finalized, the changes will shift the way practices select codes for both office and facility visits as soon as January 2021.

The list of approved changes includes deletion of Level 1 office new patient E&M code 99201. For Medicare, claims for code 99201 represented only 0.15 percent of all 266 million inpatient E&M claims in 2017, when it had a 37 percent denial rate (versus an overall E&M denial rate of 5 percent).

Understand the history and exam change before you proceed:

AMA’s Panel agreed to the removal of history and exam as key components for selection of the E&M service level. This means that the history and exam would not be used to “score” the visit for an audit. However, the practitioner would be required to document that these elements were performed in order to report an office visit code. Evidence of the history and exam should still be part of the documented record.

Practitioners would select E&M codes based on either a) the level of medical decision-making (MDM) or b) the total time spent performing the service on the day of the encounter. (Note: “time” will limit you on how many patients you can see per hour).

There is also a plan to revise the E&M guidelines into three sections:

  • Guidelines common to all E&M services;
  • Guidelines specific to an office and other outpatient visits; and
  • Guidelines specific to E&M services in the facility setting, including observation, hospital inpatient, consultations, emergency department, nursing facility, domiciliary, rest home or custodial care, and the home setting.

Total time would include “total time spent on the day of the encounter” instead of total face-to-face time.

Another component is a major overhaul of the MDM documentation guidelines to emphasize the complexity of all conditions being addressed in place of the number of diagnoses reported.

Within the office and outpatient E&M guidelines, MDM section title updates would include:

  • “Number of Diagnoses or Management Options” would become “Number and Complexity of Problems Addressed;”
  • “Amount and/or Complexity of Data to be Reviewed” would become “Amount and/or Complexity of Data to be Reviewed and Analyzed;” and
  • “Risk of Complications and/or Morbidity or Mortality” would become “Risk of Complications and/or Morbidity or Mortality of Patient Management.”

Among the additional proposed changes:

AMA proposes to make some changes to other E&M codes; for example, they would revise prolonged E&M or psychotherapy service codes 99354 and 99355, which currently read “in the office or another outpatient setting,” to “exclude reporting of office and other outpatient services codes. Also, a new 99XXX code would be added to “report prolonged office or other outpatient E&M services.” Guidelines would be revised.

One more interesting inclusion is this: AMA proposes to add guidelines for reporting time “when more than one individual performs distinct parts of an E&M service.” This will need to be clarified as to what constitutes the clinical team as part of the encounter.

Lastly, AMA proposes to add a Summary of Guideline Differences table to denote the differences between the different sets of guidelines, as well as new definitions of terms, a new MDM table, and definitions of total time associated with outpatient E&M codes. The CPT editorial panel is seeking comments through March 25.

Details are available on the AMA CPT website:


Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

Related Stories

  • AMA CPT® Editorial Panel Proposals for 2022-2023 Posted
    AMA says these are proposed, not finalized. The American Medical Association (AMA) Editorial Panel met in February to discuss proposed changes to the CPT® Code Book. The formal proposal published on March 5 was a reflection of the discussion, and…
  • CPT/AMA Announces a New PPE code – But is it Payable?
    Some third-party payers have reimbursed and will continue to reimburse providers for this new CPT code; others won’t. The American Medical Association (AMA) published a new CPT® code on Sept. 8 that accounts for extra provisions to ensure patient and provider safety during a public health emergency (PHE).  The…
  • Researching as a Core Skill for Optimal Coding
    Effective research leads to correct coding. With the 2021 ICD-10 code updates already in use and the CPT® and HCPCS updates right around the corner, this is a prime time to talk about researching as a core skill for optimal…