AMA Releases Technical Corrections for 2021 Office/Other Outpatient E/M Services Codes

AMA Releases Technical Corrections for 2021 Office/Other Outpatient E/M Services Codes

The 2021 revisions and updates to the Office or Other Outpatient E/M codes were the first changes to these codes and guidelines in nearly 30 years. Now, code selection is based on either Time or Medical Decision Making (MDM) for these office visits.

The revisions’ objectives were to “reduce the administrative burden of documentation and coding, decrease the need for audits through the addition and expansion of key definitions and guidelines, and decrease unnecessary documentation in the medical record that is not needed for patient care” (AMA, 2021). The aim is to center the documentation for E/M office visits around the way the physicians think and care for patients, rather than on mandatory standards that encouraged checking boxes and copy and paste activities. See a synopsis of the rationale for changes on the AMA website here (AMA, 2021).

Clarifications for 2021 E/M Guidelines Posted

As the new guidelines took effect, the AMA received multiple questions from users applying the guidelines. As a result, AMA issued several clarifications for Medical Decision Making to address these concerns. AMA states that these include:

• “Clarifying when reporting a test that is considered, but not selected after shared decision making
• “Providing a definition of ‘Analyzed’ for reporting tests in the data column
• “Clarifying the definition of a ‘unique’ test
• “Clarifying what is meant by ‘discussion’ between physicians, and other qualified healthcare professionals and patients
• “Providing a definition of major vs. minor surgery” (AMA, 2021)

AMA also added clarifications to the guidelines common to all E/M services. These delineate activities that coders should not consider in computing time and reporting of tests in services reported separately.

Download and Save the Updated E/M Guidelines

The AMA has published the document incorporating all of these technical corrections, with the updates highlighted in blue (AMA, 2021). As these changes are not in the 2021 code book, it will be important to review and retain these updates for use during the year. A comprehensive list of the technical corrections, as well as errata, is available here (AMA, 2021).

More Changes Coming – But Not Until 2023

AMA also announced that the remaining sections of E/M services will have major revisions effective on January 1, 2023. This would include sections such as inpatient and observation, emergency department, consultations, and other areas.

We will feature more details on these upcoming changes on the YES Blog in the coming months.

If your coding team needs assistance with these E/M services technical corrections, contact YES today to discuss our tailored coding support options or education training plans.

Ann Zeisset, RHIT, CCS, CCS-P, co-authored this article with Teri Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA.