Vasilios Nassiopoulos

As part of its goal to reduce administrative burdens on physicians, the Centers for Medicare and Medicaid Services (CMS) has introduced a final rule for Evaluation and Management (E&M) coding changes that go into effect in January 2021. Extensive revisions to the guidelines aim to minimize the amount of time physicians spend on documenting visits—prioritizing the documentation of information pertinent to patient care, creating resource-based reimbursement, and achieving less need for audits.

The move reflects a positive step forward in terms of patient care and administrative burden, yet documentation readiness hinges on a clear understanding of how the changes impact current practices. Rather than focusing on a checklist of conditions for reimbursement, documentation must prioritize a holistic view of patient care to align with the framework supporting E&M codes going forward.

The best strategies for ensuring compliance make use of ongoing monitoring and use of prospective and retrospective auditing. Coupled with the right technology-enabled workflow, these tactics can go along way toward helping the average resource-strapped provider organization avoid pitfalls and maximize reimbursement. 

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While the American Medical Association (AMA) provides a 

, key highlights that coding teams need to be aware of include:

Eliminating history & physical (H&P) exam as element for code selection

While H&Ps can still be calculated as part of the total time of a visit, they no longer serve as the basis for what level of service a clinician should choose for that visit.

Medical decision making (MDM) or total time as basis for documentation and code selection

With the changes, MDM or “total time” is now the basis for coding, with the goal of better recognizing the work involved in services that are not performed face-to-face, such as care coordination. “Total time” is now defined as the time spent with a patient that is greater than 15 minutes and includes such activities as reviewing tests, obtaining and reviewing histories, performing exams, ordering medications, tests or procedures, and counseling patients and caregivers. MDM is now based on the number and complexity of the problems addressed in an encounter, the amount of complexity associated with patient data that are analyzed, and the risk of complications.

Changing MDM criteria to focus on tasks that affect the management of a patient’s condition

As part of the changes to MDM criteria, ambiguous terms such as “mild” were removed, and terms such as “acute” or “chronic illness with systemic symptoms” are now more clearly defined.

CPT code 99201 is being eliminated since 99201 and 99202 are both straightforward and differentiated by only history and exam elements.

Creation of shorter prolonged service codes

Since time is the primary basis for code selection, when the visit exceeds 75 minutes there is an additional code to capture time in 15-minute increments when time exceeds the levels in 99205 and 99215. It can only be used with those codes and when time is the basis for code selection.

A New Perspective for Coders and Auditors

The 2021 E&M coding changes will usher in a new way of thinking in terms of auditing practices. The focus now shifts to a holistic view of the patient, the problem, and the risks.

For example, consider how age may have impacted care planning in the past. Going forward, no two patients should have the same treatment plan based on age. Providers will need to document a clear understanding of the problem— for example what kind of acuity exists and/or whether there any chronic conditions or a differential diagnosis. In terms of risk, documentation should answer questions such as: “What are the risks of having a treatment plan versus not having one?” and “What social conditions exist that impact outcomes?”

With these shifts in focus, providers face revenue integrity challenges and should prepare for these in a proactive manner. Morbidity and mortality levels will still drive MDM, and accurate diagnosis coding and level compatibility are critical. Consequently, providers should avoid non-specific codes and include comorbidities.

Documentation must support the time spent with a patient to maximize reimbursement. Insights into the patient risks, complex conditions and acuity will be paramount to support optimal revenue capture. In addition, complexity and “leveling” driven by MDM will help providers support the “why” for poor outcomes when they occur.

The financial impact of over/under coding cannot be overstated. E&M codes 99211-99205 represent 40% of total revenue on average. Thus, auditing and denial monitoring will be critical to ensure no revenue is being left behind.

 (see image at right) to help practices prepare. Working in tandem with these tactics, the best strategies draw on the power of advanced analytics, automation, and artificial intelligence tools to improve collaboration between coding, billing, and compliance teams. Solutions exist now that can extract insights from claims in near real-time and detect anomalies, fueling new and expanded insights to advance process improvement initiatives around E&M changes. And, not surprisingly, the value proposition of these tools is growing rapidly as healthcare organizations try to maximize reimbursements against current revenue shortfalls associated with the COVID-19 pandemic and rapidly changing regulations.

Healthcare stakeholders stand to benefit in significant ways with current movements aimed at achieving patient-centered care. Changes to E&M coding reflect this progress by reducing administrative burden for providers and helping them focus on their primary priority: care delivery. Providers who embrace this shift and prepare for it with the right technology-enabled workflows will be best positioned for success.

is Vice President of Product Strategy and Innovation at

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Extensive revisions aim to prioritize patient care information, resource-based reimbursement, and lessening the need for audits.

2021 E&M Changes: Avoiding pitfalls with the right technology-enabled strategy

Saying that telehealth has moved front and center amid the COVID-19 pandemic is an understatement. With the Centers for Medicare and Medicaid Services (CMS) now reimbursing for remote care models, adoption of telehealth is rapidly advancing as physicians strive to overcome barriers to continuity of care and maintain operations amid stay-at-home orders. 

 found that from March 14 to April 1, daily telehealth claims for upper respiratory infections using ICD-10 diagnosis codes from private insurance increased nearly 12 times from the daily average over the previous month. In this case, upper respiratory infections were chosen to reflect COVID-19-related illnesses prior to the introduction of a diagnosis code for COVID-19.

For many practices, telehealth is unchartered territory that poses some notable risks for reimbursement. Providers must have processes in place that ensure complete, accurate capture of documentation necessary to support codingand billing activities. Doing so will not only ensure billing compliance, but also provide a boost to the bottom line at a time when it is desperately needed. 

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Yet, whenever there is a change, especially on-the-fly during busy times, healthcare organizations should expect and prepare for some confusion and error. Acknowledging that there will be increased reimbursement risks and deploying the right strategies can ultimately mean the difference between proper reimbursement and rejected claims. 

Because telehealth is untested from a claims denial standpoint and is certain to face future regulatory scrutiny, physician practices are wise to adopt an attitude of “over-documenting” patient visits. Foundationally, strategies should entail documenting everything that happens during an encounter – the objective, assessment, and any virtual examination or evaluation of the patient. The detail should also reflect the thought process of what a provider is monitoring and ruling out regarding a patient’s condition. 

Key documentation risk areas that can impact claim approval include:

Emergency room or outpatient consultations

On the technology side, documentation must reflect audio and visual capabilities and include proof of patient consent to use technology (e.g. FaceTime, Skype) that does not qualify as privacy protected.

The novelty of these care models may lend to miscommunication or gray areas due to the virtual nature of evaluations. For example, these areas may be dependent on a patient following through with prescribed measures. To avoid liability, it will be imperative that physicians document these areas of non-compliance in the EHR with as much detail as possible.  

Telehealth compliance programs avoid and mitigate risk

As part of a comprehensive revenue integrity strategy, physician practices should proactively monitor telehealth claims to quickly identify how payers are responding to documentation practices. Questions that need to be answered as it relates to monitoring rejected claims include: Was the claim denied due to the regulations before CMS’s policy simplification? Did lack of documentation contribute to the denial? Or, was a denial related to improper codes and modifiers? 

Providers should also engage in continuous auditing of telehealth claims for proper coding and clinical documentation to minimize denials by ensuring accurate, compliant submission. These strategies require that practices stay up-to-date on evolving guidance from both government and private payers. 

Increasing resource bandwidth will likely be necessary to stay one step ahead of problems and identify opportunities for process improvement. Reassigning staff resources from areas where services have been reduced-such as billing or prior authorization departments-is one strategy that can improve the outlook. Training of coding staff must be prioritized and ongoing to recognize documentation shortfalls and ensure proper use of new telehealth codes. The reality is that clinicians will lean heavily on coder expertise during this fluid reimbursement landscape to avoid confusion.

Technology can be a critical enabler of these processes in terms of monitoring updates and changes across payer reimbursement policies and ensuring that claims comply. For example, advanced auditing solutions that automatically release new ICD-10 codes and telehealth guidance can streamline the ability of a provider to operationalize changes and support ongoing monitoring.  

While telehealth has faced its fair share of reimbursement hurdles in past years, recent movements have laid the foundation for widespread adoption and expansion of these services. Even after the effects of COVID-19 have passed, the industry will continue advancing remote care options to address looming physician shortages-although future uptake will largely rest with how payers behave when processing claims. 

Because patients will come to expect the availability of remote options following their experiences during the pandemic, forward-thinking providers are wise to start getting the revenue integrity house in order. Those who implement systems to proactively monitor and audit the health of their telehealth claims will be best positioned to optimize reimbursement during the current challenging financial climate.

 is Vice President of Product Strategy and Innovation at 

Acknowledging increased reimbursement risks and deploying the right strategies can mean the difference between proper reimbursement and rejected claims.