E/M 2021: Review 6 questions and answers to clarify the new data review rules

Why This Topic Matters

The guidance addresses common documentation scenarios that can affect how practices capture E/M data work and avoid duplicative counting. It is especially relevant for teams trying to align office visit coding practices with current CPT-based interpretation and payer expectations.

Article Sections

1. Introduction

   Overview of the revised E/M office visit data review discussion and the symposium source of the guidance.

2. Tests and follow-up visits

   Questions about when lab and other test results relate to an encounter and how follow-up interactions fit into E/M documentation.

3. Order, review or both?

   Discussion of scenarios involving ordered tests, later result review, and related follow-up encounters.

4. In-house tests

   Questions about tests performed within a practice, billing relationships, and how those situations relate to E/M reporting.