New E/M Changes and Tips for Implementation [2021]

New E/M Changes and Tips for Implementation [2021] -PracticeForces

The year 2021 brought many changes in the medical billing landscape. One of the fundamental changes is the revision of office visit and evaluation and management rules, also known as E/M guidelines. E/M services are usually high-volume and can pose a significant compliance risk for a medical practice. The E/M 2021 revision (which came into effect from January 2021) was done to reduce the time it takes to document a patient visit. It was also done to recognize the time physicians spend in performing additional services, such as care coordination.

Here’s a quick recap of the new medical billing rules and tips on implementation at your medical practice.


Revised CMS E/M 2021 Guidelines


  • History and physical exam are eliminated as elements for code selection.
  • Physicians must document patient consults basis the level of MDM (medical decision making) or total time one date of service.
  • The levels of service for new patients have reduced from five to four, while the levels of service for existing patients remains five.
  • Code 99201 is deleted.

Here is a summary of the revised codes (Source MGMA).

Summary of New E/M Changes and Tips for Implementation [2021]


When a visit takes longer than the time allowed in the new codes, prolonged service code 99417 can be used in 15-minute increments. However, extended services of less than 15 minutes should not be reported.


Time-Based E/ M Reporting


Time-based reporting includes the time a physician or qualified healthcare provider spends on face-to-face, as well as non-face-to-face interactions for ensuring patient care on the date of service. This work includes the following –

  • Time spent before the patient arrives for the appointment.
  • Time spent in performing necessary health examinations.
  • Time to counsel the patient and the family.
  • Ordering further tests, writing prescriptions, or advising further medical procedures.
  • Issuing a referral for the patient to see a specialist
  • Communicating with other healthcare professionals on the patient’s case.
  • Time spent documenting the patient’s clinical information in the EHR.
  • Reviewing current medical reports and communicating with the patient or family.

Medical Decision Making (MDM)


The level of medical decision-making is based on three factors.

  • Number and complexity of health issues addressed.
  • The amount and complexity of medical data reviewed. It includes assessment of patient’s historical test reports and documents, independent interpretation of additional medical tests, and discussions done with other physicians/ specialists on the patient’s case.
  • The level of additional risk of complications, morbidity, or mortality.

Implementing E/M 2021 Changes in Your Medical Practice


The CMS revamp of the Evaluation and Management (E/M) office visit codes has happened for the first time in twenty-five years. It is a much-demanded change to reduce the documentation burdens that interfere with patient care.  An October 2020 MGMA survey on E/M 2021 revealed that only 47 percent of healthcare providers were ready for the new E/M rules.

Here are the steps you need to take to ensure the implementation of the revised guidelines at your medical practice.

  • Train your staff and providers on the selection of 2021 E/M office visit codes based on the new guidelines. Download the comprehensive list of E/M 2021 codes for the level of MDM and ask them to sign in for the learning module ‘Office Evaluation and Management (E/M) CPT Code Revisions.’
  • Update your compliance policy for the revised codes.
  • Ensure that your practice EHR and billing software is updated for the revised 2021 E/M Codes.
  • Conduct regular audits to identify deficiencies in the documentation of E/M visits.
  • Assess how the implementation is affecting the revenue flows of your medical practice.

Remember that the revised E/M guidelines apply only to office or other outpatient codes (99202 to 99215). For all other E/M services, the guidelines remain unchanged.


Is your medical practice implementing 2021 E/M guidelines in full? Do you have queries or concerns regarding E/M visits billing? Contact us today to book a free consultation session.

Related Posts


Do you want to streamline your reimbursements?

Subscribe for actionable tips and insights to grow your medical practice >

Call Now Button