Change is coming to the world of Evaluation & Management (E&M). With the Final Rule CY2020 Physician Fee Schedule now published, we know there are big changes to be expected in 2021. The good news is that there’s a year to prepare—but you have to make good use of that time if your practice is to adapt painlessly.

At Panacea we’re keeping a close eye on the changes and have a few specific ideas on how you can make sure your organization is prepared come 2021. Let’s take a quick look at why E&M is in the hotseat, what changes are coming, and then dive into what you can be doing now to prepare.

Why Does E&M Need an Update?

E&M codes are the most frequently used codes in the physician practice, which means they’re also the most frequently audited. However, the current guidelines are incredibly cumbersome and confusing, making it easy to over-document and under-code—or the other way around.

In an effort to simplify, the Centers for Medicare and Medicaid Services (CMS) initially proposed a blended payment model. This was less than enthusiastically received (to put it mildly) within the healthcare community, and so the American Medical Association (AMA) offered to step in to revise the guidelines. The AMA and CMS teamed up to develop a set of guidelines everyone could agree on. Their mission was to “decrease the administrative burden of documentation and coding.”

The CY2020 Final Rule states that CMS will adopt the new AMA guidelines, pushing them into effect in 2021.

What Is Changing?

The most important thing to know is that at the beginning the changes will only affect office or other outpatient E&M services—in other words, basically clinic visits. These changes will not affect emergency department, hospital, home, nursing home, or preventative care visits. This means that there will now be two sets of rules and guidelines to learn and use: one for seeing patients in the office and one for seeing patients in the hospital or other settings.

The changes are also only impacting codes 99201 through 99215. In particular, code 99201 is being eliminated entirely. Organizations will now be allowed to select the level of service based on time or medical decision making (MDM). Code selection will now only be based on these two factors; history and exams will still be documented, but they will not be considered toward the selection of the level of service.

The calculation of both time and MDM will be different than it is today. But I will say this: in both cases, the new calculations are more favorable than the way they have historically been calculated. Be excited for these changes.

How Can We Prepare for 2021?

Get out and learn the guidelines! The first step is understanding what is happening so you can figure out what it means for your practice. There are a variety of articles, webinars, and continuing education opportunities out there that can help you. At Panacea, we’re working on creating more material for you as well, including a series of E&M webinars that will start in January 2020.

There are several things you need to look at as you’re putting together your preparation plan for the next year. Make sure you…

  • Know the guidelines and what codes to select and how to document to support your selections.
  • Prepare your providers to know how to document for the new guidelines.
  • Change your EMR templates to support correct documentation.
  • Know the financial impact to your practice—will it be positive, negative, or neutral?

These new guidelines are big changes to some of the most commonly used codes we have. If you don’t learn the changes you simply won’t know how to code anymore. And if you can’t code correctly then you can’t get paid correctly and you become a compliance risk.

Don’t put yourself in compliance and financial risk. Learn the new E&M guidelines and start preparing now for 2021!


Written by:  Kathy Pride, RHIT, CPC, CCS-P, Panacea, Senior Vice President, Coding and Compliance

Editors Note: This article originally appeared on November 26, 2019 on ICD10monitor.com.