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Effects of 2021 E/M Code Changes

The Evaluation and Management (E/M) Coding and guidelines are about to get hit by the most significant set of changes since their very inception.

With effect from January 1st, 2021, there would be changes in the established codes that will have an impact on everyone in the health care system. Whether they assign codes or manage the health information or someone who pays the claims, these modifications are going to affect everyone.

While the first set of changes is limited to just a few variations, more of these can be rolled out in the coming future. However, one thing that you need to know is the E/M modifications aren’t going to impact massively. Contrary to your expectations, the impact of these changes will not be as big as it has been perceived. Let us now explore what are these new additions and alterations and what actual impact are they going to pose:

Outpatient Office Visit Codes Will Show a Change

The first thing that one needs to know is these variations are limited only to CPT 99201 – 99215. These changes will affect physicians who are in private practice while specialists and hospitals will remain unaffected. In the upcoming year, the new patient codes from 99202 – 99205 will not require the typical 3 key components. Instead, it will be based on the total time spent. Level 1 Code 99201 will not be included.

Only Medicare Will Make E/M Change 

CMS doesn’t possess a direct authority over any of the commercial insurance plans. Excluding the Medicare Advantage Plans, no other commercial payer is “bound to” follow these modifications. As a lot of physicians are generally oblivious of patient’s insurance, the E/M Changes will allow the physicians to have relaxed documentation rules which means they will not have to follow the existing stringent documentation rules. In all probabilities, physicians wouldn’t want to make their workflow tedious by bringing in the said variations. Hence, it would be comparatively easy to disregard the E/M changes.

Reduced Number of Medicare Patients

One of the biggest impacts of the E/M changes in 2021 is going to be on those physicians who specialize in adult primary care. For these physicians, the modification in the E/M code brings quicker documentation. But with this, there is a question, will they be willing to bring a variation in the cadence with which they function? For some physicians, the answer might be a yes but for some, they answer may be in negative. Each patient, who is not on Medicare, will require an E/M note under the existing standards. If there are a large number of patients who are not on Medicare then it would only increase the documentation under the prevailing rigorous standards.

Time-Saving Documentation

Those familiar with the E/M coding, spend less time on the documentation of level 2 and level 3 visits. Level 2 visits and level 3 visits represent straightforward and low complexity Medical Decision Making (MDM). Level 4 and Level 5 would be great time savers as these represent Moderate and High Complexity Medical Decision Making. Level 4s and 5s constitute the major visits in specialties. With the coding modifications, there is an improvement as there will be elimination of the prevailing counseling requirement. With effect from January’21, the providers will not have to establish the quantity of time that was devoted to counseling and coordination on the day.

Medical Necessity is Still the Predominant Criterion 

Under the 2021 rules, the levels 2, 3, and 4 will be paid the same amount. The level 5 codes will hold their prevailing higher payment. Nothing will make a difference to the fact that medical necessity is the most significant driver of the code level. The chosen code level in the note must reflect the respective level of the medical necessity. New rules do not imply that the physicians have the liberty to pick any level out of 2, 3 and 4 just because they pay same. It is mandatory for the physicians to pick the code level as per the severity of the existing problem, intensity of the management and other remaining aspects of the medical necessities. 

In the remaining part of 2020, providers shall continue to follow the existing coding guidelines in determining the level of a new encounter. But it is advised to begin planning for the upcoming year.


To know all about E/M changes, connect with your coders, and create a plan for the associated physicians and staff to ensure a seamless transition from January 01st 2021. To comply with the alterations, it is advised to begin early with strategic planning of everything.