September 2, 2020

2021 E&M Changes – Improving physician efficiency or creating a battleground?

Daisy Roberts

Changes are ready to hit the outpatient clinic and private office world come January 2021 with the relaxation of documentation requirements specific to the assignment (or coding) of professional fee Evaluation & Management Levels.

In a nutshell – the changes ease up on hitting several specific documentation elements (HPI, PFSH, ROS, and Exam components) for determining current E&M level assignment and focus more upon documentation of MDM, and only pertinent History and Exam elements medically.  There is also expansion of the ability to use time as a basis for level determination as well.  These changes to criteria considered (or counted) in a level assignment affect the office/outpatient E&M code set 99201-99215 only… so for office/clinic settings.

The facility world however is not changing – both from a professional fee coding perspective (inpatient, observation, & emergency settings guidelines for E&M leveling do not change here in January), and also from the general documentation requirements perspective long required from Joint Commission standards and other regulatory bodies, including CMS.  Review of systems, physical exams, and all types of patient histories are still requirements in the facility-based world.

Many physicians may not argue with pre-surgical H&P requirements, or even inpatient admission requirements for a full history & physical currently… but those arguments could start up with confusion over the new E&M changes.  We all know clinic and office visit notes are frequently where the H&P is documented.  Considering these very same physician office or clinic notes are often used as the H&P itself – the battleground could be over what is required in relation to physician understanding and expectations of documentation requirements.

There is some debate out there over how much this changes a physician’s daily documenting life versus the process of coding that documentation for billing proper levels – regardless, you should consider several preparation steps to make sure you align your physicians, documentation requirements, and workflows in the outpatient arena.

  • Review documentation requirements – as always, the Joint Commission and others allow for the organized medical staff to identify requirements. Do your Bylaws, Rules & Regulations or any facility/clinic policies stipulate any of these documentation elements?
  • Review and update provider documentation templates, smart phrases, etc. in your EHR – across both your ambulatory and facility side. In my opinion, the promise of physician efficiency with this change is not realized if you do not address these documentation formats. 
  • Review your charge capture/assignment protocols and workflows – are physicians selecting E&M levels in clinic workflow or is it calculated with either a system or human (coder) assistance? Education will be important for both physicians and coders, and system adjustments may also be needed.
  • Review potential impacts to changes in reimbursement values – depending upon the make-up of your organization with physician practices or clinics, you or your physicians could be affected by shifting RVU values.
  • Review and update any revenue integrity, compliance, and coding audit plans for ongoing review – while you can project potential pitfalls and impacts now, it will be reviewing the results and mobilizing the appropriate responses that will ensure long-term success.


The Wilshire group is here to help – We can assist you with Coding/CAC workflow, EPIC PB and HB workflows, EHR optimization and revenue cycle process across the board.  Contact us today and let us share our deep knowledge and experiences with you for operational improvements across your revenue cycle.


Daisy Roberts

Senior Strategic Advisor

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