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

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).


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.

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