For the first time in 25 years, significant changes have been made to the evaluation and management (E&M) coding and billing guidelines. As a result, there are potential compliance risks that providers should keep in mind when coding and billing for E&M services.

It is important to note that the 2021 E&M changes apply only to services provided in the physician office or hospital outpatient setting. All other E&M services, such as those performed in the inpatient setting, are unchanged and continue to follow the 1995/1997 guidelines.

One of the changes is that time may be the basis for selecting the level of E&M service regardless of whether counseling or care coordination occurred. When utilizing time as the basis for determining the E&M level, it is important to remember:

1. Calculation of time can include both face-to-face time and non-face-to-face time
2. Time can only include time spent on the same day as the patient encounter
3. Calculation of time can include time spent:

• • preparing to see the patient – reviewing data and records
  • ordering medications, tests or procedures
  • referring or communicating with other health care professionals
  • documenting in the medical record
  • interpreting test results
  • communicating information to the patient, family or caregiver
  • care coordination

4. When clinicians jointly perform an E&M service, the time spent can only be counted once
5. Clinician staff time may not be included in the calculation of time
6. Calculation of time may not include activities which are separately coded and/or billed
7. Time spent must be must be supported by the documentation in the medical record

Also, remember, there are a finite number of hours in a day so the combined documented time for all patients seen on a particular day should be reasonable given the fixed number of hours in a day.

Another change is that the history and physical are no longer required elements to support the level of E&M service. However, in the majority of cases they will provide information that informs medical decision making and the appropriate course of treatment. As such, it will continue to be important to document the relevant history and physical information in the medical record.

Lastly, when using medical decision making instead of time as the basis for the E&M level, note that the AMA Documentation Guidelines Table of Risk has been revised to reflect guideline and definition changes. In order to compliantly classify medical decision making, it is important to be familiar with the new guidelines and definitions.

E&M services are the most frequently billed health care service and the most frequently audited. This coupled with the 2021 changes, make it important to be aware of the risks when coding and billing for E&M services in order to ensure compliant practices.

Please contact us if you have any questions. We are here to help!

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