Everything You Need To Know About Coding Changes in 2021

E/M and coding changes in the past few months have led many people to wonder what changes will happen with outpatient documentation. Many changes have been made to the AMA Current Procedural Terminology (CPT) code set, which is predicted to only apply to outpatient and office settings and not inpatient, home care, or nursing home E/M.

These changes are going to reduce the need for auditing, which is going to reduce physician burnout and “note bloat.” This aims to help physicians and guarantee that E/M service payments are resource-based to streamline the process.


Some important coding changes to keep in mind are that the components for code selection have been reduced to two, which help with medical decision-making (MDM) and total time on the day of the encounter.

Some of the changes you should be aware of about MRM coding are as follows.

The amount of and the complexity of problems that can be discussed in an encounter have been affected, which means that many of the diagnoses a patient has received do not have to be mentioned in the document apart from the ones discussed or addressed in that particular visit.

The amount of and complexity of the reviewed and studied data has been changed. This means that much of the repetitive and redundant data that healthcare providers previously had to enter into their documents is no longer required. Unless that data is relevant to their visit, it does not have to be entered.

The risks and complications and the morbidity of patient management have been affected. This refers to the social reasons a healthcare provider can decide not to admit a patient or change their treatment.

Previously, social determinants were not included as a reason in the documentation. These kinds of social determinants include things such as whether it is viable for a patient to undergo certain treatments and whether they have the transportation means to undergo that treatment at the clinic.

Some of the changes you should be aware of about E/M time are as follows.

Previously, E/M time meant that healthcare providers and doctors had to mention how much time they spent engaging in in-person contact with a patient. However, because of the coronavirus and advancements and changes in medical practices, this time also includes the time doctors spend not in person on the day of the encounter.

When working with codes, time was an important criterion that determined which kinds of codes needed to be sleeved based on ranges of minutes for both new and old patients.

The option to mention time, regardless of whether the care and treatment decided during the visit is determined by previous counseling or discussion before the visit. Previously, the option to mention time in these situations was not available.

The expectation is that MDM codes are supposed to be the most frequently used by physicians. However, the codes related to time are a better representation of how much time each patient encounter takes up, even when these encounters are rated lower on the MDM scale.

Because they take up a large amount of time and energy by the physician, regardless of whether they spend that time discussing medical untruths or clearing a misunderstanding in the medical world, they are considered a part of the time-related coding.

Some other aspects of time-related coding include the time physicians spend reviewing and assessing the tests that belong to a patient before the patient comes in for the visit. It also includes the time they spend talking to a patient’s family and caretakers about their condition or the information they need to take better care of them.

It also includes discussing test results with a patient over the telephone. This time also includes the time physicians spend ordering certain tests or procedures to be performed for their patients and the time they spend working at home towards a cause related to their patients.


Some other important coding changes include the reduction of the history and physical exams that physicians had to include in their documentation previously. These were previously key elements in deciding the code level of a visit and have now been moved to make space for more determinants.

There will be a larger number of payment packages with the onset of added codes, as they are irrelevant for every department. For example, these codes lead to more payment bundles for departments such as maternity care but will not significantly influence surgical global payment bundles.

While the changes will impact the billing process, how insurance companies work with the healthcare facilities, and how different inpatient and outpatient visits are understood, they were made to make life easier for healthcare providers in terms of the time they spend on documentation.

It also helps to notice and pay tribute to the time they spend on tasks conventionally not part of the documentation system, such as time spent on counseling and working at home. With telemedicine and telehealth practices on the rise, proper payment and billing procedures must be taken to reduce burnout and adjust to the changing times.


These changes and E/M office visit guidelines are set to take place from January 1st, 2021. It is encouraged for all healthcare facilities and physicians to get a clearer idea before then.

If you need help with your medical billing, payment, and collection, contact us for our full services. We help take away from your workload regarding payments and documentation so you have more time to devote to patient care.

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