2021 Evaluation and Management Guidelines for Outpatients

Medical professionals and all the relevant personnel can rejoice! Gone are the days when they had to count the the number of checked bullet points to determine what Evaluation and Management (E&M) level to assign to an outpatient office visit. By January 1, 2021, the new set of 2021 E&M Guidelines simplifies E&M selection process. Through this set of guidelines, all the physician has to do is choose between time-based billing or medical decision making, depending on what is more financially beneficial. 

What is the E&M Guideline?

The Evaluation and Management coding system is a coding process that helps make medical billing more efficient. Medical service providers in the United Statesa re required to use medical coding to receive reimbursements from public and private medical insurance programs whenever they clients avail their service. 

The original standard and guidelines for E&M was first established by the American Congress in 1995 and has been revised several times since then to meet the changing needs of patients and payers across the country. E&M documentation has to be complete, comprehensive, and accurate to ensure an efficient and accurate claiming process.

E&M has three major components – history, exam, and medical decision making. 

What are the changes in the 2021 E&M Guidelines for outpatients?

In the 2021 E&M Guidelines, each of the major components were re-evaluated and streamlined to focus more on the provider-patient relationship and to prevent tiring out medical providers.

Changes in History and Exam

After the 2021 E&M Guidelines were implemented, the history and exam components of E&M only has to be medically appropriate, lessening the time spent on documentation and fulfilling requirements, and increasing the time spent on delivering direct medical care to the patients. However, even if history and exam documentation are no longer factored directly with E&M leveling  and no longer needs to fit a specific type, physicians are still encourage to be accurately document the patient encounter for legal and post-payment review matters.

Changes in Medical Decision Making (MDM)

Medical Decision Making or MDM has four types: straightforward, low complexity, moderate complexity, or high complexity. In the new 2021 E&M Guidelines, these types are retained but instead of using a complicated point system, medical professionals and service providers can now refer to an MDM table that outlines the requirements for each E&M level.

In the new MDM table, physicians  receive compensation for compex MDM no matter how long the patient encounter is as long all the supporting documents show medical necessity.

Changes in Time-Based Billing

In the old guidelines, physicians are only allowed to choose an E&M level when they spend more than 50% of their time with the patient on counseling or coordinating care. In the 2021 E&M Guidelines, physicians can now count the time in the total time of the visit on the day of the patient encounter that may include patient counseling and care coordination. 

The new guidelines make delivering and receiving medical care more efficient and goal-orientated, placing the focus on patient welfare instead of billing. All in all, the 2021 E&M Guidelines meet the demands of status quo.