Merriam-Webster, which tracks changes to the evolution of the English language, added 535 new words and terms to its dictionary this year, such as “COVID-19,” “physical distancing” and “self-isolate.”

E/M coding update checklist

Get step-by-step advice on navigating the office visit documentation coding changes and meet the January 2021 deadline for CMS’ E/M coding update with confidence.

Similarly, the 2021 AMA Current Procedural Terminology (CPT®) code set—long described as the “common language of medicine”—includes 329 editorial changes from last year’s edition.

The codes are developed by the work of hundreds of volunteers and describe the work of physicians and other qualified health care professionals—from office visits to genetic testing. The 2021 set has 206 new codes, 54 deletions and 69 revisions that reflect the emergence of new medical technologies and testing services sparked by the COVID-19 pandemic.

The most significant changes are connected to the first major overhaul in more than 25 years of the code descriptors and guidelines for evaluation and management (E/M) services delivered during office visits and other outpatient encounters.

These foundational modifications aim to make E/M office-visit coding and documentation simpler and more flexible, while eliminating clinically irrelevant administrative burdens that diverted physicians’ attention away from patient care.

The Centers for Medicare & Medicaid Services has proposed adopting the code modifications on Jan. 1. They include:

  • Eliminating history and physical exam as elements for code selection.
  • Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making or total time.
  • Promoting payer consistency with more detail added to CPT code descriptors and guidelines.

Related Coverage

How 2021 E/M guidelines could ease physicians’ documentation burdens

“To get the full benefit of the burden relief from the E/M office visit changes, health care organizations need to understand and be ready to use the revised CPT codes and guidelines by Jan. 1, 2021,” said AMA President Susan R. Bailey, MD.

“The AMA is helping physicians and health care organizations prepare now for the transition and offers authoritative resources to anticipate the operational, infrastructural and administrative workflow adjustments that will result from the pending transition,” Dr. Bailey added.

These resources include a checklist, videos, modules, guidebooks and other useful tools for adopting the new codes and guidelines.

Dig deeper on how 2021 E/M guidelines could ease physicians’ documentation burdens.

The CPT code set is kept current through the work of the CPT Editorial Panel, an independent body convened by the AMA. The panel collects input from the health care community and beyond to ensure CPT content reflects the coding demands of digital health, precision medicine, augmented intelligence, and other aspects of a modern health care system.

The CPT Editorial Panel

Work on the new E/M office visit codes and guidelines began in 2018, when the AMA assembled a joint work group representing the CPT Editorial Panel and the RVS Update Committee (RUC), a volunteer group of 31 physicians who advise Medicare on how to value a physician's work. 

The workgroup was led by Barbara Levy, MD, a former RUC chair, and Peter Hollmann, MD, former chair of the CPT Editorial Panel. Together a “strong consensus across the house of medicine” was built through an iterative process that involved assembling some 300 participants on group calls, surveying them, and then using the results to form the agenda for the next call.

Dr. Hollman, a geriatrician and chief medical officer of the Brown Medicine faculty medical group, had some basic advice for physicians on this high-impact transition.

“Think about all the stuff that drives you crazy,” he said. “And then check to see if you have to do it anymore.”

Earlier this year, the Editorial Panel moved quickly to develop and adopt a new code for laboratory testing for the novel coronavirus—SARS-CoV-2—which causes COVID-19.

Related Coverage

E/M office-visit changes on track for 2021: What doctors must know

But that was only one example of the CPT Editorial Panel’s ability to keeps pace with the industry’s rapidly changing landscape. In fact, the Editorial Panel has held 6 special virtual meetings during the public health emergency (PHE) to address coding for SARS-CoV-2 testing.

In addition to responding rapidly to the needs to the health care community during the pandemic, coding was developed to describe and support innovative digital medicine services that included screening patients for diabetic retinopathy with automated point-of-care augmented-intelligence technology.

New codes also describe and support continuous cardiac monitoring that uses algorithmic technology working in concert with a wearable patch that provides more accurate and complete data for physician interpretation.

A section on CPT content education has been created for the AMA Ed Hub™ online leaning platform containing CME modules covering E/M codes, Clinical Examples of Radiology, as well as an overview of CPT coding basics.

Coding books and products, including the CPT 2021 Professional Codebook,  can be ordered from the AMA Store. The 2021 CPT codes and descriptors can be imported straight into existing claims and billing software using the downloadable CPT 2021 Data File. The file contains the updated code set’s complete descriptor package, including official descriptors for consumers and physicians, and the complete official CPT coding guidelines.

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