Evaluation and Management 2021-How is it Going?

We are now in Q1 with putting the 2021 E&M guidelines into practice to document and select the levels for our outpatient/office visits.  The promises made for these changes were “Patients over Paperwork” and “Reducing Provider Burden.”  At first glance, it all seemed simple. Providers, coders, as well as administrators were looking forward to eliminating the need to include unnecessary information in the medical record to meet the bulleted requirements for each element of a visit.

The good news is that the AMA has worked hard to fulfill these promises, and Medicare has agreed to accept the new regulations.  Also, the increase in work relative value units for office/outpatient services and the last-minute boost in the conversion factor have resulted in an 8% increase in reimbursement for pain management providers when reporting these codes.

As ACE has begun to audit records for 2021, we have made some interesting observations.  In many instances, the “note bloat” that was supposed to disappear with the new rules’ implementation is still present.  The practice of “copy and paste” or pulling information forward from previous encounters remains. Although we have seen some groups adding a statement about the time spent with the patient, no real attempt at meaningful revision to documentation has been noted.

To benefit from the time-saving capability of the 2021 rules, providers will need to be open to change and be willing to invest in revising their visit templates. The previous formatting does not lend itself to capturing the new definitions for time-based reporting or the more clearly delineated elements for documenting medical-decision-making.  To facilitate the ability to choose either method, (depending on which is more beneficial to the provider), the template must have the capacity to capture the necessary information for both models.

Calculating E&M Level Based on Time

When reporting levels based on time, it is critical to include all provider time, both face-to-face with the patient and allowed non-face-to-face time.  Although the AMA and CMS have indicated that only the total time spent must be documented, they have cautioned that other third-party payers may have additional criteria. ACE recommends that the visit template include not only the total time but also the ability to indicate which activities (of those designated in the guidelines) were actually performed. This will avoid a cloned statement erroneously stating that time was spent on every action for every visit.

Another caveat related to time reporting is the importance of noting the actual time spent.  Indicating the same time frame for every patient, such as 45 minutes for new patients and 30 minutes for established patients or basing the time on the interval scheduled, would present a risk to the practice.  Payers will be looking for this strategy, and you do not want to trigger an audit.  Also, make sure only physician/ non-physician practitioner time is included.  Time spent by office staff is not countable. On March 9, 2021, the AMA published CPT Errata and Technical Corrections 2021 with further clarification on issues with the new rules. They emphasized that any time spent ordering, performing and/or interpreting diagnostic tests/studies during an encounter is not included in total time if the test/study is separately reported. Although timekeeping in this regard may be a challenge, remember, no “double-dipping” (billing for the time and billing for the test) is allowed.

Your first stop for time capture would be to reach out to your EMR vendor.  Discover what they may have available to facilitate noting the actual time.  The capability to capture both face-to-face and non-face-to-face time, which may be performed at different intervals throughout the day, is crucial.  If your EMR cannot do this electronically, providers will need to be educated to manually enter time blocks spent on the day of the visit for each patient.

One final thought on coding by time.  Remember-it is the total time on the date of the encounter.  A review of records the night before or documenting your note the day after the visit is not countable time.  Ask yourself, do I need to change my process to incorporate these additional activities into the same day as a patient encounter? If not, I will either lose that pre-and post-time, potentially lowering the E&M level, or I may need to consider determining the visit level by medical decision-making.

Medical Decision Making

You may be more familiar with calculating the level of medical-decision-making since it has been one of the elements of an E&M service since 1995. But don’t assume it is entirely the same as your previous understanding of the requirements.  The AMA has provided numerous specific definitions and criteria that impact our analysis of each of the three elements involved.  Let’s look at some of the crucial principles as they relate to your practice.

The AMA has provided some key definitions to help us determine the level for the first key element, ‘Number and Complexity of Problems Addressed.’  It has always been necessary to stipulate if a condition is acute or chronic.  However, now, to label a disorder ‘chronic,’ it must be expected to last at least a year or until the patient’s death.  Another common term has also been defined. An illness is considered ‘stable’ when treatment goals for the condition have been met. That’s right! If the treatment goals have not been achieved, the patient is not stable.

From these definitions, we glean some important documentation ‘musts.  Make sure to qualify whether a condition is acute or chronic, based on the specific AMA definition. Treatment goals for each condition or problem you are treating at the current encounter should be delineated and the status of the progress toward meeting those goals assessed.  Setting the goals for a pain management patient, for instance, would typically involve a discussion with the patient, outlining the pain score or the functional capability improvement that may realistically be expected.  This should be tailored to each patient and not a cloned statement.  The AMA has stated that providers should distinguish exacerbations, the progression of the condition or side effects of treatment and whether these are considered severe (significant risk of morbidity and may require hospital care). It may be helpful to discuss this with all providers in the practice to establish specialty-specific, consistent guidelines for these terms.

One final caveat for this element. Beware of ‘unbundling’ the patient’s problems. Clusters of symptoms should be treated as one condition.  For instance, low back pain symptoms should not be indicated as separate problems spinal stenosis, degenerative disc disease, etc. Conversely, if the patient has low back pain due to those disorders and has foot pain due to diabetic peripheral neuropathy, two illnesses would be appropriate.

Amount and Complexity of Data to be Reviewed and Analyzed

The ‘Amount and Complexity of Data to be Reviewed and Analyzed’ has been extensively revised, with numerous definitions and quantification of the elements. Be sure to consult the table provided by the AMA for the requirements for each level.  Here are some points to keep in mind.  If you or someone of the same specialty in your group orders a test, count it when ordered but not when reviewing the result. When a test is countable, each separate test (it has its own CPT code) may be tallied. However, if you bill separately for the test itself (e.g., urine drug test in your office), you may not also count it under data.

The use of an independent historian is considered more complex in the new regulations. Ensure, if using an independent historian, to document the medical necessity for their use and what additional information they provided.  This must augment, not duplicate, what has been provided by the patient.  The March 9th update clarified that this information does not need to be provided in person but must come directly from the historian.

When considering whether to count your independent interpretation of a test, make sure you can answer ‘yes’ to the following questions: 1) Did someone from outside my practice (or within my practice of a different specialty) perform, interpret, and report this test? 2) Does the record denote my personal specific interpretation of the data? And most importantly, 3) Was it medically necessary for me to perform an independent review?

Finally, discussion of test results or management with another appropriate source was expanded to potentially include not only medical clinicians but non-medical professionals such as caseworkers, teachers, social workers, etc. Be sure to include documentation of this other source’s relationship to the patient’s case and how the information will be used in managing the patient’s care.

In the March 9th update, the AMA explained that a combination of different data elements allows these elements to be summed. It is not required that each item type or category be represented.  For instance, a test ordered, plus a note reviewed, plus the use of an independent historian would count as three elements.  They also specified that discussion of a test result or management of the patient with an outside provider must be interactive, direct (not through office staff), must be done outside of the progress note (e.g., phone call, email, etc.), and clearly include the response from the outside provider.

Risk of Complications and/or Morbidity or Mortality of Patient Management

This last MDM element has also undergone extensive changes to assist the provider in assessing risk for an encounter.  Based on the previous table of risk, you should be aware of some clarifying detail from the AMA.  Many pain management patients have been prescribed various medications either as the primary treatment or in conjunction with interventional pain procedures. Both modalities are noted in the moderate risk category, with additional considerations for the procedures.

In an alert published March 8, 20201, by National Government Services, documentation requirements to credit the provider with prescription drug management were delineated. The provider must record the following: drug(s) considered, why they are being considered, changes in the patient’s condition that may have resulted in the decision to discontinue a drug, vary the drug dosage, or start a new medication and possible adverse effects, potential benefits, etc. ACE recommends recording the 6As of drug management (analgesia, adverse effects, daily living activities, aberrant behavior, affect and adjunct therapies) to meet these criteria.

In the past, a procedure’s global period determined whether a procedure was major or minor.  This is now left to the discretion of the provider. When making this determination, factors such as the location at which the procedure is performed (office versus hospital) and the requirement for sedation/anesthesia should be considered.  Most interventional pain procedures are considered minor procedures. The risk of a procedure may vary based on patient co-morbidities or issues that may make it more hazardous such as previous hardware placement, congenital anomalies, etc. It is crucial that considerations of that nature be recorded in the medical record and the specific reasons the risk is greater. A discussion between your providers to establish guidelines for evaluating procedure risks may promote a more consistent application of these principles.

A new consideration has been added to the moderate risk category.  Social Determinates of Health (SDOH) allows the provider to include such risks as housing insecurity, literacy, economic circumstances, etc., that directly affect patient management decisions. Recording these situations and how they impact treatment options’ feasibility is key to supporting this risk factor.  The social issues that impact your patients would also be a good topic for discussion between your providers.

ACE queried the AMA whether narcotic management would be considered “Drug Therapy Requiring Intensive Monitoring for Toxicity,” which falls in the high-risk category. Many of our pain management clients felt this was legitimate considering the multiple risks in monitoring patients on controlled substances. The AMA disagreed with this position, stating they did not feel that this treatment met this category’s criteria. Pain specialists should check with their societies concerning further efforts to have the AMA reconsider this decision.

As we have noted, it is critical that documentation provides support for the level of medical decision-making billed. One suggestion would be to record a SOAP note for each problem. This provides an auditor a clear indication of how the requirements for each element were met.

Subjective – What is the problem, complaint that brings the patient in today? (Includes appropriate history).   Problem(s)

ObjectiveWhat data will help me diagnose this problem? (Includes appropriate exam.)Data

Assessment – What is my diagnosis?

Plan – How will I manage this problem? Risk


As was mentioned at the beginning of this article, change may be necessary for you to take advantage of the helpful revisions in the E&M guidelines.  When driven by knowledge and the proper tools, change can reap a harvest of benefits for both patients and providers.  Start today with an analysis of your current E&M template. Assess what may need to be added or revised to capture the information outlined in the 2021 guidelines efficiently. Education for all providers and coders is essential for success in using this new E&M model. Stay tuned for any additional updates or clarifications.

© 2021, Auditing for Compliance & Education, Inc.