General Surgery Coding Alert - 2021 Issue 1
Part B Coding Coach: Add This E/M Overview to Your Resources
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Article Overview
This article explains major 2021 office and outpatient evaluation and management updates and why they matter for coders reviewing Medicare Part B documentation and claim preparation. It covers the removal of one established office/outpatient code, the expanded role of time and medical decision-making, and the updated way office/outpatient E/M descriptors are framed. The discussion is aimed at coding professionals, auditors, and reimbursement staff who need a high-level understanding of the revised guidance and its impact on resource use.
Why This Topic Matters
These E/M updates affect how office and outpatient visits are documented, reviewed, and selected for reporting. Understanding the scope of the changes helps coding professionals stay current with revised documentation expectations and level selection framework.
Article Sections
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Introduction
A brief overview of the 2021 office and outpatient E/M update cycle and why it is being revisited.
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Demise of 99201
A discussion of the removal of one established office/outpatient E/M code and the surrounding rationale at a high level.
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Expanded Roles for Time and MDM
A summary of how visit level selection now emphasizes time and medical decision-making for office/outpatient E/M services.
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Know These Details on New E/M Descriptors
An overview of how the remaining office/outpatient E/M descriptors were revised and how history and examination are presented in the new framework.
What You Will Learn
- The overall purpose of the 2021 office/outpatient E/M revisions
- How the article frames the removal of one office/outpatient code
- How time and medical decision-making factor into level selection
- What changed in the structure of the updated E/M descriptors
- Why these changes matter for documentation and coding workflow
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Reimbursement specialists
- Revenue cycle professionals
Codes Discussed
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