Implementing CPT® Evaluation and Management (E/M) revisions

A stethoscope sits on the counter in a doctor's office.

Together, the AMA and Centers for Medicare & Medicaid Services (CMS) have achieved the first overhaul of evaluation and management (E/M) office visit documentation and coding in almost 30 years. These landmark E/M office visit code changes deploy Jan. 1, 2021.

These revisions have the potential to significantly reduce physician burden and improve patient care. However, in order to properly implement these large-scale changes, active planning is critical.  As the authoritative source on the CPT® code set, the AMA is committed to assisting the health care community transition with as little friction as possible.

E/M CPT learning module

This educational module provides an overview of the evaluation and management (E/M) code revisions and shows how it differs from current coding requirements and terminology.

On Jan. 23, 2020, the CPT®/RUC Workgroup on E/M hosted a panel presentation to help the health care community hit the ground running when the E/M office visit documentation and coding changes deploy on Jan. 1, 2021.



How did we get here and what changes can you expect?

Chris Jagmin, MD, vice chair of the CPT® Editorial Panel, presents the history of the CPT®/RUC Workgroup on E/M and an overview of the revisions to the 2021 E/M office visit CPT® codes.



Using MDM criteria to document an office visit

Peter Hollmann, MD, co-chair of the CPT®/RUC Workgroup on E/M, elaborates on how to use the new medical decision making (MDM) criteria to select a level of service.



Using time to select a code level

Barbara Levy, MD, co-chair of the CPT®/RUC Workgroup on E/M, elaborates on how to select a code in the office or other outpatient setting using total time on the date of the encounter.

Review questions and answers regarding Medical Decision Making (MDM), time and documentation not specifically covered in other CPT coding guidance, and find out how to apply to the 2021 guidelines. 

Sign up for CPT News

Get the latest news on CPT codes and content emailed directly to your inbox each month from the CPT authority. All subscriptions are free!

Learn how to optimize documentation and coding strategies in just 4 STEPS. Download the toolkit.