Coding Background Image

Exceptional Coders | Innovative Technology

CMS Latest Final Rule Updates Office/Outpatient E/M Coding and Documentation Policies

Posted by David Fong on Nov 15, 2019 6:00:00 AM


The Centers for Medicare & Medicaid Services (CMS) issued a final rule earlier this month that includes updates to payment policies and rates for services provided under the Medicare Physician Fee Schedule (PFS) effective on or after January 1, 2020, as well as updates to its E/M coding starting on January 1, 2021.


Medicare Physician Fee Schedule (PFS)

For calendar year 2020, these changes include a budget neutrality increase to the physician fee schedule rates by 0.14% for calendar year 2020. The finalized CY 2020 PFS conversion factor will be $36.09, an increase of $0.05 above CY 2019’s $36.04.  In addition, CMS added three new codes for Medicare telehealth services: HCPCS codes G2086, G2087, G2088, which describe a bundled episode of care for treatment of opioid use disorders.


Changes to Evaluation and Management (E/M) Coding

The final rule press release notes that it is aligning E/M coding with changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits for calendar year 2021. Among the changes beginning January 1, 2021:

  • Retain five levels of coding for established patients
  • Reduce the number of levels to five for office/outpatient E/M visits for new patients with increased payment by using new recommended values for the office/outpatient E/M visit codes. It was found that office/outpatient E/M visits are generally more complex and require additional resources for most clinicians.
  • Revise the code definitions


American Medical Association President Patrice A. Harris, MD, was quoted in HealthLeaders that its association worked with CMS to complete the first overhaul of E/M office visit documentation and coding in more than 25 years.  "Physicians spend a huge amount time meeting burdensome documentation requirements during patient interactions, which takes time away from patients and contributes significantly to burnout and professional dissatisfaction, Harris said. “This new approach is a significant step in reducing administrative burdens that get in the way of patient care."


The AMA said that key elements of the E/M office visit coding changes include:

  • Eliminating history and physical exam as elements for code selection. While significant to both visit time and medical decision-making, these elements alone should not determine a visit's code level.
  • Allowing physicians to choose whether their documentation is based on medical decision-making or total time. This builds on the movement to better recognize the work involved in non-face-to-face services like care coordination.
  • Modifying MDM criteria to move away from simply adding up tasks to focus on tasks that affect the management of a patient’s condition.


Review and Verification of Medical Record Documentation

CMS also finalized broad modifications to the documentation policy so that physicians, physician assistants, and advanced practice registered nurses (APRNs – nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists) can review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, medical, physician assistant, and APRN students, nurses, or other members of the medical team.


According to the CMS press release, this final rule is projected at full implementation to save clinicians 2.3 million hours per year in burden reduction.


Aviacode understands these changes.  Our Senior Vice President of Client Operations recently presented “Patients over Paperwork: E/M Options” at the HCCA Clinical Practice Compliance Conference.  Understanding the impact to these coding changes allow Aviacode’s team to code accurately and quickly, and thereby reducing first-pass denials and receiving optimized reimbursements.  Our team of experienced and AAPC and AHIMA certified coders accurately code more than 10 million encounters per year, helping providers avoid costly mistakes and improve their revenue integrity.


Topics: ICD-10, Medical Coding, Coding Compliance, Pro-Fee Coding, Facility Coding