practice management

E&M Updates in 2021: Frequently Asked Questions

How many ways to code an E&M visit? After January 1st, 2021, there are two -- time and medical decision-making. The American Medical Association’s 2021 updates to the Evaluation and Management codes are here, which means there are important considerations for pediatricians whose work centers on outpatient visits. According to the AMA, these changes are designed to simplify work and offer physicians more time with patients. To better adjust to these changes and learn more about the choices physicians have when billing E&M codes, we spoke with PCC’s Jan Blanchard, a certified coder and experienced pediatric consultant to learn how pediatricians can prepare.

How to Get Started with E&M in 2021 and Beyond

Starting January 1st, 2021, pediatric practices will need to change the way they capture visit notes, the way their workflows operate, the way they level a visit, and subsequently, the way they level their E&M visits. 

Based on AMA resources and the coding procedure manual for 2021, PCC has created a tool for pediatricians and other billable providers to use as a reference for the new guidelines designed to help pediatric offices and auditors adjust to the changes. Physicians will need to adjust their thinking away from considering history or physical when leveling a visit. With preparation and practice with tools like this one, the guidelines will become a routine part of the physician’s daily tasks.

When can a physician use this E&M coding tool? If the visit turns out to level higher in complexity, the tool is readily available to use during the visit. However, since all activities performed on the date of service are applicable to the “time” criterion, a pediatrician should tally time at the end of the day to include all activities performed during, before, and after the visit. Jan reminds practices that no matter whether “complexity” or “time” is higher, providers should select the highest level appropriate, to achieve subsequent appropriate payments.

To get started with the tool, Jan recommends providers assess an encounter document using the columns in the tool to decide where you think that visit lands in the 2-5 continuum. Next, decide where the visit lands in regards to time. Jan recommends measuring both for complexity and time in order to support reporting the higher level.

Frequently Asked Questions: Strep? Common Cold? Common Levels?

In answering some of the more frequent questions pediatricians have on the 2021 E&M changes, Jan has some reassuring advice for practices. “My primary advice in this realm is to capture what you do; the rest can be figured out later. Your primary role in this is capturing everything you do -- you cannot delegate this. There’s always someone to whom you may delegate audit and education on the levels later. First, capitalize on the experience with the patient that day.”

How should I level for common visits such as strep or common cold?

Perhaps the greatest adjustment for pediatricians will likely not be in the coding for common diagnoses, but how physicians think about the visit in order to arrive at the appropriate code or level. “Previously,” she says, “Primary care pediatricians were more dependent on the history and physical parts of the visit than the medical complexity and time to choose levels. So a shift is necessary to adjust to a patient’s condition and the total time spent working a case on the visit date to come to the appropriate level.”

Practicing with the new guidelines using completed visit encounters can be useful for pediatricians to familiarize themselves with the changes. Jan also reports some positive news: when comparing previous guidelines with the new ones during her audits for 2020, she found that physicians were almost equally likely to meet the mark.

Worried about penalties or audits?

Jan cautions pediatricians that their risk for an audit may increase if their coding is inconsistent, but for the most part, no payor will be out to penalize a practice for a typical physician’s learning curve with the new guidelines. She also notes that it’s possible to misunderstand the guidelines or to level for what the physician thinks the visit should be, instead of adhering to guidelines. Audits and education are important for both physicians, billers, and auditors.

If a practice is faced with an audit, the results can be challenged. She encourages practices to review results and present their case appropriately. In this situation, early preparation can help practices know exactly where they stand during an audit.

Will I ever be able to level to a 4 or 5?

The short answer is yes, and more easily than you might think. Many common situations in pediatrics will level to a 4 or 5. One example: to level appropriately to a 99214, a physician would need to satisfy one of 3 categories using, for example, prior external notes, an independent historian, and an interpretation of a test by another physician. In a not-uncommon circumstance for pediatricians, this is accomplished in an Emergency Department follow up visit with a parent as historian, review of an ED report, and independently interpreting a test from that ED visit.

Practices may be wondering if these changes are really for the better of their business and practice of medicine. Simply put, the AMA’s goals in implementing these changes are to reduce paperwork and simplify the way physicians level for visits. Despite a learning curve and the mental adjustment away from physical and history that pediatricians will have to make, Jan sees the changes as ultimately a positive shift. “The goals the AMA has are simplification and paperwork reduction and I think they’ve met both of those. The thing I like best about the simplification is that it returns the history and physical to their use as tools by a pediatrician in diagnosis and treatment, and not for coding.”

The 2021 E&M Changes

To learn more about the changes in the E&M outpatient codes, be sure to visit our previous post on this subject, E&M 2021 Updates: Preparing Your Pediatric Practice, with insights from Jan and Chip Hart, PCC’s Director of Pediatric Solutions. To recap, four of the major changes are:

  • Medical Decision-Making Ousts Physical and History. MDM decisions will now factor more than the physical and history in leveling a visit.
  • Complexity. No more leveling based on established or new patients or on the patient’s history. Just 2 of the 3 medical decision making sub-elements are required.
  • The Definition of Time. All activities on the date of encounter count towards the level but do not count against the level. This allows appropriate levels for the amount of work performed (such as prep work, charting, and ordering labs).
  • RVU Impacts. Changes to the Medicare Conversion Factor mean that the 2021 updates will undergo a complex set of changes, meaning important changes to a practice’s revenue.

The changes in the documentation requirements  reflect more closely the work that pediatricians do before, during, and after a visit.

To prepare for the E&M updates that will affect the way physicians think about leveling visits, be sure to visit our previous post on the subject, and begin to learn how your practice can shift its thinking, reduce paperwork, and get back to the most important business of caring for patients.The 2021 E&M Coding Worksheet For Pediatricians

Allie Squires

Allie Squires is PCC's Marketing Content Writer and a transplant from upstate New York. She holds a master's in Professional Writing from NYU.