12 Tips for E/M Coding Success

July 19, 2022 |
Nicki Bucceri, RHIA, Senior Manager, Coding Solutions, DeliverHealth
July 19, 2022
Nicki Bucceri, RHIA, Senior Manager, Coding Solutions, DeliverHealth

January 1, 2021 marked a major milestone in the medical coding world. After more than 20 years, the American Medical Association’s (AMA) new guidelines for Evaluation and Management (E/M) Coding for outpatient and office settings finally went into effect. The AMA designed the 2021 E/M code changes to reduce the documentation burden on providers and make documentation more clinically relevant.

With all new guidelines comes a host of questions, especially for physicians, midlevel providers, and medical coders. The last year has been one filled with trial and error as coding teams became familiar with the rules. But now, best practices are starting to emerge that can help coders set up their teams—and their providers—for success.

These 12 helpful hints, tips and tricks can help medical coders make outpatient and office coding simpler for physicians and midlevel providers:

1. Ensure you document a medically appropriate history and exam. One of the biggest adjustments in the 2021 E/M code changes is that history and exam no longer impact code selection for outpatient and office visits. However, they are still required, and we advise providers to keep documenting them.

Tip: Consider setting up templates within the EHR that require providers to fill in the history and exam field before they can close and sign a note. You can include an “N/A” option, too, if you wish. A template will help remind providers that it’s important to document history and exam even though those two fields aren’t assessed the same way they were previously.


2. Choose medical decision making (MDM) or time. Coders may utilize whichever one favors the best possible reimbursement.

Tip: This doesn’t have to be all-or-nothing. You can choose to utilize MDM or time on a per-encounter basis. However, if you do choose to utilize by time, we recommend developing a practice-wide policy for documenting time across all patient records.


3. Differentiate between new and established patients. This is a carryover from the old E/M outpatient and office standards. New patients are those that haven’t been seen by the provider group or specialty in the last three years. Reimbursement is higher for new patients.

Tip: Scoring patients by MDM is the same whether it’s a new or established patient. However, if you use time to assign to the E/M level, new patients must meet a 15-minute minimum threshold. If a new patient visit fails to meet that threshold, you must score that encounter by MDM.


4. Document all problems and how you are addressing them. Problems are diseases, conditions, injuries, symptoms, signs, findings and/or complaints. Address means to manage, evaluate and/or treat.


5. Document the nature of each problem addressed. When scoring patients by MDM, the 2021 E/M code changes categorize problems the following way:

N/A – These are typically nurse-only visits with no problem to be documented.

Minimal – These are patients seen for self-limited or minor problems. The CPT code defines a self-limited problem as something that “runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter the health status.”

Tip: We recommend that practices compile internal guidance to help define self-limited problems for coders to use.

Low – These are patients with two or more self-limited or minor problems, one stable chronic illness, or one acute uncomplicated illness or injury. CPT defines uncomplicated illness or injury as “a short-term problem with low risk of morbidity for which treatment is considered.”

Tip: Sometimes a self-limited or minor problem that’s not resolving on its own and for which treatment may be considered may elevate the patient’s problem addressed to an acute uncomplicated problem.

Moderate – These are patients with one or more chronic illnesses with exacerbation, progression or side effects from treatment; two or more stable, chronic illnesses; or one undiagnosed new problem with an uncertain prognosis.

High – These are patients with one or more chronic illnesses with severe exacerbation, progression or side effects of treatment, or one acute or chronic illness or injury that poses a threat to life or bodily function.


6. Determine the amount or complexity of data to be reviewed and analyzed. When evaluating encounters for data reviewed and analyzed, it is important to ensure you are counting each unique piece of data only once. Data is generally produced from one of these five sources:

  • Tests – The review and ordering of tests can be counted. However, each unique test can only be counted once. A unique test is defined by CPT code. For example, a liver function panel counts as one test. In addition, you may only count tests that relate to the patient’s problem addressed; do not count preventative testing.

Tip: Consider enacting practice-wide policies to reduce your risk for double-counting tests. For example, if your providers always order tests in conjunction with an office visit, you can create a policy to only count tests upon order and not review.

  • External notes – These are notes from another healthcare organization, facility, or physician. Again, you can only count these once. If you review records from a patient’s recent hospital stay that contain notes from various providers, you may only count that set of notes once, because it’s from one source.
  • Independent historian – This is any person involved with the patient—such as a parent, guardian, surrogate, spouse or witness—who provides any additional history.

Tip: If you use an independent historian, clearly state whether there was medical necessity for doing so. This isn’t required, but notating this will substantially mitigate your risk in an audit.

  • Independent interpretation of a test for which a CPT code exists, and an interpretation or report is customary.
  • Discussion of management or test interpretation with external providers or appropriate sources. An external provider is someone not in the group practice. An appropriate source is a non-healthcare, non-family member involved in patient management, such as a parole officer or case manager.


7. Clearly state your assessment of the patient’s risk level as it pertains to complications of patient management. This is an area that changed very little in the 2021 E/M code changes. CPT still recognizes four areas of risk—minimal, low, moderate, or high—terms that are familiar to providers and don’t require quantifying definitions.


8. Summarize all treatments, including treatments considered but not carried out or decided against. Consideration of further testing or treatment but electing not to proceed based on a risk/benefit analysis or patient choice still represents risk of patient management so long as it occurred within that patient’s visit on that date of service.


9. Record total exact time in minutes that was required for the visit. If you score patient visits by time, your documentation must include the total and exact time the provider spent delivering the care of that patient. This can include both face-to-face time and non-face-to-face time (such as reviewing labs or records pre-visit or ordering medications and communicating with referring physicians post-visit). Record only time spent by the provider and not time spent by ancillary staff or time spent on procedures.

Tip: Remove any old verbiage from your templates that referred to “typical time.” These may include phrases such as “about 30 minutes with patient” or “more than 50% of time for care coordination.” Using old “typical time” phrasing may cause you to miss out on revenue.


10. For shared visits, record the amount of time spent by each provider, including any overlapping time. Shared visits represent a particularly tricky area in the E/M code changes for outpatient and office visits when determining the billing provider, which is required to be the provider responsible for the substantive portion of the visit.

The Center for Medicare and Medicaid Services is considering 2022 as a “transitional year.” That means you may determine which provider performed the “substantive portion” of a shared visit by either noting:

  • The provider who accounted for more than 50% of service time, or
  • The provider who completed and documented one of the key elements of the E/M level in its entirety

However, for 2023, determining the provider who performed the substantive portion of a shared visit will revert back to CMS’ original guidance of more than 50% of service time.

Tip: Get your providers acclimated to tracking and reporting time now. Come January 2023, you will need to use that time to determine the “more than 50%” threshold that will determine the substantive portion of a shared visit.


11. Documentation should occur on the same day of the visit. If not, include a reason for the late entry. If using time, total time may only include time spent in the care of that patient on the same date of service as the face-to-face visit. So, if a provider completes their documentation on the same day as the patient visit, this time may be included in the total time. But if that provider completes their documentation the day after the visit, time spent documenting the visit may not be counted towards total visit time.


12. Go above and beyond. Document the start/stop time of any procedures separately reported, or otherwise differentiate those procedures from total service time. This will help avoid any confusion about time spent on procedures vs. time spent on the office visit.

If you want to know how Coding and Revenue Integrity solutions and expertise from DeliverHealth can help make outpatient and office coding simpler for physicians, midlevel providers, and medical coders, let’s talk.