2021 E/M Changes: Are You Ready

Why This Topic Matters

The 2021 E/M changes affected how office visits were documented, reviewed, and leveled, making them important for compliance, training, and revenue cycle preparedness. Practices that understood the new framework were better positioned to reduce disruption and align coding workflows with the updated CPT guidance.

Article Sections

1. CMS Has E/M on Their Radar

   Background on CMS activity leading up to the 2021 office visit E/M update, including the broader policy context and adoption timeline.

2. And Then…… COVID

   How the pandemic affected preparation for the upcoming E/M changes and delayed operational focus in many practices.

3. New CPT Guidelines

   An overview of the updated CPT office visit guidance, including documentation concepts and revised terminology used in the 2021 framework.

4. New Ways to Level E/M Services

   The two general approaches described for selecting office visit levels under the updated guidance.

5. Coding by Time

   Discussion of the time-based approach and the categories of work that may be considered when using that method.

6. Coding by Medical Decision Making (MDM)

   Discussion of the medical decision-making approach, including the structure of the revised MDM framework and related office visit changes.

7. New MDM Table

   A description of the revised office visit MDM table and how it fits into the updated leveling process.

8. Preparation for January 1, 2021

   Recommended practice preparation activities such as education, impact assessment, communication planning, and system readiness.

9. Conclusion

   A summary of the main preparation themes and final transition reminders for practices implementing the 2021 changes.