HCPro, JustCoding Outpatient - 2019 Issue 17 (April)
Approved E/M documentation updates and changes on the horizon for 2021
April 23rd, 2019
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Article Overview
This article explains approved and anticipated evaluation and management documentation changes tied to AMA CPT Editorial Panel activity and CMS Medicare Physician Fee Schedule updates. It is intended for coders, auditors, compliance staff, and clinicians who need to understand the scope of the 2019, 2020, and 2021 changes, including revisions to documentation structure, service-level selection, and related guidance for office, outpatient, and facility settings.
Why This Topic Matters
E/M documentation changes affect some of the most frequently reported services in healthcare, so updates can influence workflow, audit readiness, and claim reporting across multiple care settings. Knowing what is changing and when helps organizations prepare for policy alignment and documentation review.
Article Sections
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Changes for CYs 2019 and 2021
Introduces approved documentation updates already in effect and those planned for later implementation. Covers broad categories of E/M services and the organizations involved in the update process.
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Future E/M selection
Discusses upcoming changes to how visit levels may be selected and documented. Also addresses the relationship between documentation methods and payer variation.
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Payment calculations, guideline updates
Summarizes expected changes to payment structure, add-on reporting concepts, and documentation language. Also describes broader revisions to medical decision-making guidance and audit considerations.
What You Will Learn
- The general scope of approved and proposed E/M documentation updates
- Which care settings are affected by the upcoming guideline revisions
- How documentation approaches for E/M services are being restructured
- What types of payment and add-on reporting changes are being discussed
- How AMA and CMS policy updates relate to future E/M guidance
Who Should Read This
- Medical coders
- Coding auditors
- HIM professionals
- Compliance staff
- Physicians and non-physician practitioners
- Practice managers
Codes Discussed
Code Ranges Discussed
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