2021 E/M changes: Same-day visits and procedures can’t have overlapping time

Why This Topic Matters

The article highlights practical documentation and code-selection issues that affect E/M reporting accuracy when a visit and procedure occur together. It also addresses broader 2021 guidance that can influence medical decision-making documentation and audit readiness.

Article Sections

1. Same-day visit and procedure reporting

   Discusses the scenario used to illustrate separate reporting of an office visit and a procedure during the same encounter. The section centers on documentation concepts and time considerations under CPT office visit reporting.

2. Time-based reporting considerations

   Explains how time is treated when selecting office visit levels based on time rather than medical decision-making. The section also notes the relationship between concurrent services and counted time.

3. Independent historian and data scoring

   Covers guidance on whether an interpreter can be counted in the data component and how independent historian concepts are applied. It also introduces related data-counting principles for office E/M services.

4. Additional 2021 E/M guideline points

   Summarizes several other topics from the 2021 guidance, including data timing, repeated counting of tests, separately billed services, and how surgical global days relate to risk assessment.