CHICAGO — The American Medical Association (AMA) is helping physician practices integrate fundamental changes to the coding and documentation of evaluation and management (E/M) office visit services that account for nearly $23 billion in Medicare spending. New Medicare office-visit coding and documentation guidelines are simpler and more flexible, but physician practices will need to prepare in the new year to get the full benefit of the burden relief the changes are designed to bring.



The AMA worked with the Centers for Medicare & Medicaid Services (CMS) and convened specialty societies and other health professionals to simplify the requirements, make them clinically relevant, and reduce excessive documentation burden. Key elements of the E/M office visit overhaul include:

• Eliminating history and physical exam as elements for code selection. While significant to both visit time and medical decision-making, these elements alone should not determine a visit’s code level.
• Allowing physicians to choose whether their documentation is based on medical decision-making (MDM) or total time. This builds on the movement to better recognize the work involved in non-face-to-face services like care coordination.
• Modifying MDM criteria to move away from simply adding up tasks to focus on tasks that affect the management of a patient’s condition.

“These foundational changes are intended to reduce documentation burden and provide physicians more time with patients, not paperwork, said AMA President Patrice A. Harris, M.D., M.A. “There’s a lot to understand and to prepare for before the new guidelines take effect Jan. 1, 2021. The AMA is helping physician practices to start planning now and offers resources to anticipate the operational, infrastructural and administrative workflow adjustments that will result from this overhaul.”



The following 10-point AMA checklist and linked resources will help guide physician practices for a smooth transition to the simpler and more flexible guidelines:

• Identify a project lead
• Schedule team preparation time
• Update practice protocols
• Consider coding support
• Be aware of medical malpractice liability 
• Guard against fraud & abuse law infractions
• Update your compliance plan
• Check with your electronic health record vendor
• Assess financial impact
• Understand additional employer or payor or medical liability coverage requirements

To learn more about these significant CPT code set revisions, visit the CPT E/M webpage. Additionally, the AMA has created an interactive educational module, a detailed description of the code and guideline changes, along with a table illustrating medical decision making revision to educate physicians practices.