CPT®

E/M prep: Your in-house practice checklist for 2021 transition

New Medicare office-visit coding guidelines are simpler and more flexible, but physician practices will need to prepare to get the full benefit of the burden relief the changes are designed to bring. Learn more about what you should be doing within your practice to make a smooth transition.

Office Evaluation and Management (E/M) CPT Code Revisions

This educational module provides an overview of the new E/M code revisions and shows how it will differ from current coding requirements and terminology.

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The revised coding guidelines for outpatient evaluation and management (E/M) services represent the first major overhaul of E/M reporting in more than 25 years. They also have significant potential to give doctors more time to spend with patients by freeing them from clinically irrelevant administrative burdens that led to time-wasting note bloat and box checking.

These changes include:

  • Eliminating history and physical exam as elements for code selection.
  • Allowing physicians to choose whether their documentation is based on medical decision-making (MDM) or total time.
  • Modifying MDM criteria to move away from simply adding up tasks to focus on tasks that affect the management of a patient’s condition.

While administrative burdens are reduced, practices still need to get ready for when the revisions take effect Jan. 1, 2021. The AMA has a checklist and other resources to help implement the operational, infrastructure and workflow changes that will allow practices to more readily—as CMS would say—put patients before paperwork.

The AMA offers tools and resources to help practices transition to the new reporting guidelines.

These include an AMA Ed Hub™ module, "Office Evaluation and Management (E/M) CPT Code Revisions," which will help physicians and practice staff understand how these foundational changes will impact their work, a detailed description of the code and guideline changes, and a table illustrating revisions related to MDM documentation.

Three activities that a practice may immediately initiate include the following.

Identify a project lead. The transition will require staff education, review of internal policies and procedures, and careful financial tracking. Picking the right person to ensure that all components of the transition are executed in a timely manner is critical. An AMA STEPS Forward™ module on organizational leadership and change management provides advice.

Schedule team preparation time. The best way to educate your practice about these upcoming changes will be to walk through them with the practice’s physicians, other clinical staff and administrative personnel. Schedule time for in-person gatherings to review the changes and address questions that arise. An AMA STEPS Forward module outlines how to run an efficient and productive team meeting.

Update practice protocols. It is important that practice procedures and protocols are updated to be consistent with the new guidelines. The AMA recommends leveraging your practice’s established coding resources and expertise early in the update process.

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The revised guidelines were developed by a workgroup assembled by the AMA representing its Current Procedural Terminology (CPT®) Editorial Panel and the AMA/Specialty Society RVS Update Committee (RUC). Last summer and fall, the group built consensus through group calls with some 300 people on the line, surveying those participants, and then using the results to form an agenda for the next call.

The workgroup was led by Barbara Levy, MD, a former RUC chair, and Peter Hollmann, MD, former chair of the CPT Editorial Panel.

“I think it will take a little while to get used to—but not very long, because this will be far more intuitive for physicians,” Dr. Levy said. “For doctors, it’s going to be terrific.”

She explained that the new documentation will be based on the traditional SOAP—subjective, objective, assessment and plan—in which physicians would document what the patient was there for (subjective), what was learned from their history and exam (objective), and then what the physician assessed to be the problem, and the plan for dealing with it.

“That’s the way our brains work,” Dr. Levy said. “We’re getting to the place where we’re documenting what’s important for patient care and for communication with our colleagues.”

Dr. Hollmann agreed.

“Mostly what physicians will be doing is undoing certain ingrained habits for documentation that were created by the CMS documentation guidelines,” he said. “At some point, they’ll be saying ‘Why am I still doing this?’”