Guidelines for E/M Coding 2021

In order to reduce the administrative burden of coding guidelines, the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Board and the U.S. Centers for Medicare & Medicaid Services (CMS) have proposed simplifications of the official evaluation and management (E/M) coding system to begin January 2021. The Guidelines for E/M Coding define the requirements for individual E/M codes based on the extent of the documentation of the three key components.

Guidelines for E/M Coding 2021

History Component

  • The History component includes the chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family, and social history (PFSH) sections.
  • A chief complaint (CC) must be documented for every visit, and it is typically stated in the patient’s own words. The history of present illness (HPI) uses descriptive elements to document the current problem(s). For non-Medicare patients, the CC and HPI must be obtained and documented by the physician who is the billing provider. 
  • Information pertaining to the review of systems (ROS) and past, family, and social history (PFSH) sections may be recorded. The physician must attest to reviewing this information and comment on pertinent positive and negative responses. During follow-up visits, any changes, or lack thereof, should be documented with a date reference. 
  • The PFSH involves a review of 3 areas: past, family, and social history. Pertinent positive or negative responses may be documented. Statements such as ’on contributory without further description are not acceptable.
  • For new and established patients, a statement may be placed above your signature. This concise statement adequately declares that the billing provider has properly assessed all necessary components for complete documentation of the encounter. It also verifies that the physician acknowledges their role in reviewing this information for billing purposes. 

Medical Decision-Making Component

  • The medical decision-making (MDM) component consists of 3 parts: Data, Diagnosis, and Risk. These indirectly measure the complexity of the patient encounter. This component is considered more complex for patients undergoing multiple tests, with multiple diagnoses, and with multiple risk factors. The risk of treatment options as they pertain to the individual patient should be included here. 
  • In general, MDM is a metric of the workup performed by the physician to develop a medical diagnosis, while medical necessity should then validate the complexity of the MDM. 


  • Occasionally, time may be a factor in determining the level of service. This may influence CPT code selection if the visit predominantly consists of counseling and/or care coordination. In this instance, greater than half (50%) of the time spent face-to-face between the physician and the patient (not including non-providers) in an outpatient setting must consist of counseling and/or care coordination. 
  • The content of those activities must then be summarized in the documentation. Time spent reviewing records while the provider is not with the patient does not qualify. In addition, face-to-face time should be ‘rounded down’ in the documentation. The provider must include the following in their note: total face-to-face time, that >50% of the face-to-face time was spent counseling and/or coordinating care, and a summary of the discussion.

CMS has launched its ’Patients Over Paperwork’ initiative to reduce the burden caused by Medicare documentation requirements. In keeping with this idea, CMS suggested multiple changes to E/M services, including collapsing the payments from the current 5 levels (99201 to 99205, 99211 to 99215) for new and established patients into 2 levels. CMS proposed 1 payment for Level-1 codes 99201 and 99211, and 1 payment for all other levels (99202 to 99205, 99212 to 99215). Required documentation only needs to support a Level-2 visit to justify the new blended payment. More than 15,000 comments were submitted regarding this change. Due to the comments, CMS will continue to recognize all 5 levels of outpatient E/M services for new (9920x) and established patients (9921x).

MBC has been assisting clients in preparation for the 2021 E/M changes. We offer both modeling services and chart reviews to help hospitals plan for reimbursement, provider compensation, and compliance factors that will result from these changes. Get in touch with us for more information.