The updates in the 2021 Evaluation and Management guidelines will mean moving the way you think on selecting the appropriate visit codes for your acute visits. In this article, we’ll cover the changes we need to expect and tips to prepare your practice, and resources to make this coding pivot a smooth running for your practice.

What’s changing and why?

The American Medical Association has announced updates to the definitions of Evaluation and Management codes which go into effect on January 1st, 2021. To clarify, the 2021 updates only affect the E&M outpatient codes. This means that if your practice’s physicians render inpatient care or Emergency Department services, these updates do not affect these procedures.
By streamlining documentation requirements for these visits, these changes are intended to simplify the way you level visits, reducing “note bloat” and increasing time with patients. In addition, these changes are a response to the widespread use of electronic health records (EHRs) and the associated complexities in working with them.

There are four major changes in the 2021 updates.

1. Medical Decision-Making over History and Physical

Before 2021, as defined by AMA, physicians level their codes based on three key elements: history, physical, and medical decision-making. In the future, only medical decision-making factors into leveling . Selecting the code is no longer dependent upon whether a patient is new or established; instead, the visit codes are selected based on medical decision-making, without any involvement of the history and physical. The history and physical will remain important parts of each visit, though. This method simplifies the way physicians choose codes for each sub-element because the level will be the same for new and established patients. This is intended to more accurately represent the complexity of care required by the patient’s condition(s) and save a little time every day by helping clinicians document to a level and then selecting the appropriate code.

2. The 2 of 3 Rule for Complexity Levels:

The encounter will need to meet the 2 of 3 rule for any patient. These changes align very closely with the work that pediatricians do. The focus is on making the process of documenting and leveling easier on clinicians. The elements required to level a visit (based on complexity) will no longer require the ‘3 of 3 rule’ applied to new patients and the history sub-elements. Instead, just 2 of the three medical decision-making sub-elements are required. Medical decision-making depends upon the nature and number of problems the patient reports, the data used to make decisions, and the risk posed to the patient by the chosen management of their problems. Each unique test, order, or document counts as a contribution to the data segment, as does each unique contributing historian. AMA’s 2 of 3 rule, as outlined in this table.

3. The Time Definition

When making a level choice based upon time, Starting 2021, time spent doing all of the clinician’s activities on the date of the encounter will count. This includes the all the clinical activities physicians do that are billable for a visit, without being limited to the time spent in the exam room or with the patient. These activities include preparing for the visit by reviewing history, ordering tests or labs, and consulting with other healthcare professionals. This change has even more relevance to more experienced clinicians. It means that while with the benefit of their experience, they may complete a visit more quickly than a less experienced clinician might, this time does not count against the complexity of the decision-making. Clinicians can prepare for this change by reviewing the current process of notes, charting, and the tools they use. Pediatricians can prepare in more detail for these changes with the help of the AAP Coding Newsletter, which from January 2020 on has broken down elements of the 2021 updates for better understanding. Clients of PCC receive the Newsletter as part of their PCC Care Plan.

4. RVU Impacts

Changes to the Medicare Conversion Factor mean that the 2021 updates will undergo a complex set of changes. RVUs are set to increase. This may have an impact on your practice’s revenue.
There is an estimated increase of about 31% in work RVUs by weighted volume. There is an estimated decrease of about a 12% decrease in the Medicare Conversion Factor, which affects the actual charges related to all codes. Overall, the changes are positive for pediatricians and likely to have an impact on your practice revenue.