The Changing E/M Environment- What You Need to Know

Last year, CMS proposed sweeping changes to the physician evaluation and management (E/M) rules.  The proposed changes were a result of increasing industry pressure and complaints that our current E/M guidelines are clinically outdated, are not meaningful and don’t account for the differences in patient complexity and care.  As electronic health record documentation has evolved, multiple agencies have expressed concern over E/M coding based on the “volume” of documentation.  CMS has stated, “documentation has proliferated to support visit level in a way that bloats the medical record and prevents ready access to the most important information for patient care”.

This year, CMS has proposed modifications to the E/M changes released last year in an effort to more closely align with the AMA’s new E/M guidelines.  If the proposed changes are finalized, they will go in to effect January 1, 2021.  With these changes impacting virtually every provider in the country, and with just over a year to prepare, it is critical that everyone understand the changes and how they are going to impact their operations.

We have prepared an outline of the key 2021 changes you and your staff need to know based on the most recent proposals.

  • CPT 99201 will be deleted
  • CMS will establish separate payment rates for the remaining codes (99202-99205 and 99211-99215)
    • This is a change from the initial proposal of a single blended payment rate for levels 2-4
  • E/M levels will be assigned based on either time or medical decision making (MDM)
    • History and exam will no longer be used in determining the level of service and providers should document a medically appropriate history and exam.
  • CMS will adopt the new AMA CPT interpretive guidelines for determining the level of MDM
  • CMS will adopt the new AMA CPT time descriptors, by code, that include all practitioner time the day of the visit
  • CMS will adopt the new AMA CPT codes for prolonged services (CPT 99xxx, 99358, 99359)
    • This is a change from the initial proposal of reporting extended service code GPRO1
  • CMS will adopt RUC-recommended value increase payments for E/M services
  • CMS will revise add-on code GPC1X and delete GCG0X
    • This is a change from the initial proposal.  Add-on code GCP1X will now be described as, “Visit complexity inherent to E/M associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition).

The AMA has published the revised E/M code descriptors, level of service times, definitions for MDM and rules for use.  These new guidelines may be accessed at:

The CMS Proposed Physician Fee schedule is located at:

The E/M changes are substantial.  Providers, coders and auditors should start receiving regular training regarding the changes and testing should be utilized to assess proficiency with the new rules.  You should also start having regular discussions with your IT and electronic health vendors to ensure templates and automated coding systems are updated to accommodate the new guidelines. 

HBE has expertise in E/M services and we have been following the proposed changes closely.  We are available to assist your organization with the necessary training for both clinical and coding staff as well as providing assistance to you with preparedness evaluations and testing.

Recent Posts






Ready to discuss your project with us?