CPT 2021 Coding Webinar

The Center for Medicare and Medicaid Services (CMS), with guidance from the American Medical Association (AMA) implemented a new evaluation and management (E/M) coding system for outpatient visits effective January 1, 2021. This was the first change in 25 years and was developed to ease the documentation burden on medical providers.

The updated CMS guidelines are based only on 1) a clearer method of assigning MDM or 2) a new methodology for assigning a time component to the visit on the date of service. 

The new guidelines:

  • Eliminates the history and physical as elements for code selection
  • Gives providers the option of choosing whether documentation is based on MDM or time associated with the visit on the date of service
  • Modifies the criteria for MDM by removing ambiguous terms, clearly defines important terms and concepts and re-defines the Data MDM measures 

As in the past, CMS recognizes 4 levels of MDM (straightforward, low complexity, moderate complexity, and high complexity).  MDM quantifies the complexity of establishing a diagnosis and/or selecting management options by measuring:

•   The number and complexity of problems addressed at the encounter

•   Amount and or complexity of data to be reviewed and analyzed 

•   The risk of complications, and/or morbidity, of patient management 

Coding by time

Indicating the time associated with an encounter is an alternative method of determining the level of the visit. For many, utilizing time to determine a level of service is much less confusing and more straightforward compared to assigning a level of service using MDM. In contrast to pre-2021 method of assigning time associated with the face-to-face time spent counseling the patient or coordinating care, now time consists of the following elements:

  • Time spent preparing to see the patient, reviewing tests and external notes
  • Time spent obtaining a history from the parent
  • Time spent performing an examination
  • Time spent ordering medication or tests 
  • Time spent referring to, and if necessary, communicating with other health care providers regarding management
  • Time spent documenting in the health record
  • Time spent communicating results (on the day of service) with the patient/family or caregiver
  • Time spent in care coordination

This webinar discusses the new coding system in detail.  

In the opinion of Dr. Schuman, the data element component of MDM remains too complicated and rarely elevates an office visits category appropriately. A more practical method is to code by time.

My son, Robert Schuman and I have developed MDMtool.org to assist providers in coding according to the new guidelines.  One selects elements of MDM or time associated with a visit (coming soon) and copy and pastes the text into the bottom of your note. My other suggestion to avoid audits is to list as many appropriate visit diagnoses as one can. 



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