2021 brings huge updates to the E&M Guidelines for codes office visits. Here are the most important things to know:
- These changes only apply to office visits, the guidelines for all other places of service remain unchanged. These changes apply to all payors.
- The level of Medical Decision Making should guide the level of service billed. History and Physical examination no longer define the level of service for office visits.
- There are three elements of medical decision making: number and complexity of problems addressed, amount and/ or complexity of data reviewed, risk of complications and/or morbidity or mortality of patient management. The level of service is determined by meeting 2 out of 3 of these elements. This chart from the AMA best describes this, click to enlarge:You can find a printable version of this grid here.
- It is important to note that for review of data, you can only count tests that you are not separately billing for. You can only count data for one encounter, if you review the same data across multiple visits you can only count it for the first visit
- Your level of service can also be determined by the amount of time spent on the encounter on the date of service. Time spent documenting and reviewing records count towards total time, but it must take place on the same date of service. Only time personally spent by the practitioner counts, you cannot count work done by medical assistants or other staff towards the total time of the visit. The table below shows the time ranges for each level of service.
As always, if you didn’t document it, it didn’t happen. If you are billing based on time spent, document the total time spent and how you spent the time. Make sure to appropriately document problems addressed, data reviewed, prescription drug management, and any relevant social determinants of health. Please let us know if you’d like to work together on updating your EMR templates based on these new guidelines.