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Implementation Guidance for FY21 E/M Code Changes

On January 1, 2021, the American Medical Association will implement the largest change to the CPT* evaluation and management (E/M) office visit codes in almost 30 years. The code changes impact some of the most frequently used E/M codes (office and other outpatient visit codes 99201-99205 and 99211-99215) requiring significant changes in provider office and other outpatient visit documentation.

This article is intended to assist with planning for and ultimately successfully transitioning to the new E/M codes. There are several important steps providers must consider in developing an implementation plan. UASI presents the steps below as a general guide. Large, complex healthcare organizations may need to add or expand the steps, whereas smaller, less complex organizations may develop a more simplistic implementation plan.

The time needed to complete implementation steps will also depend on the size and complexity of the organization. Steps one and two should be completed as soon as possible and will help determine the amount of time and required budget to complete the remaining steps. The steps presented here are not necessarily sequential. Some steps are prerequisites, such as steps one and two, but other steps can be performed concomitantly. Healthcare provider organizations should begin steps one and two immediately. A delay in initiating these steps could result in significant challenges for a successful transition to the FY21 E/M code changes.

Step 1: Organize and Define Responsibilities

The first step toward a successful transition to the new E/M codes is to identify a Project Manager and establish an interdepartmental Task Force. An Implementation Task Force is necessary to address the multiple aspects of the transition including for example, an EHR assessment and preparation, organizational communication, financial impact analysis, physician and staff education, internal policy and procedure review, and follow-up activities. The size and scope of the Task Force should reflect the size and complexity of the organization. A consistent meeting schedule should be established, keeping in mind more frequent meetings may be necessary in the immediate pre- and post-implementation periods. At a minimum, consider including representatives from the following departments: Executive (senior) management, Medical Staff, HIM/Coding, Finance, IT, and Compliance. Define individual responsibilities to establish and carry out an implementation plan. Aim to divide and conquer.

Step 2: Conduct Impact Assessments

Identify all areas and services that report Office and Other Outpatient E/M codes, especially for new and established patient office visits. Evaluate processes for assigning and reporting these codes, which can vary greatly among different providers, practices or specialties. Determine how E/M codes are assigned in each area, including those assigned by: providers, professional coders, other office staff or perhaps automatically via the EHR. This will help identify the breadth of the impact to the organization.

Another important tactic to assess the extent of the impact is to perform a dual E/M coding analysis. Review a sample of office visits, comparing code level assignment based on today’s E/M codes and guidelines with E/M code level assignment based on the FY21 CPT* E/M codes. Variances identified in this comparison will provide insight on the potential impact of the E/M code changes and help determine priorities for a successful transition, including for example documentation improvement priorities and provider training needs. Extrapolating the results of the dual coding analysis to the broader patient population, based on E/M code utilization patterns, can help determine the financial impact of the transition and potentially cost-justify training and other implementation activities. To fully assess the financial impact, use the dual coding results to not only forecast E/M shifts but also calculate changes in total relative value units.

Documentation gaps identified in the dual coding analysis may necessitate changes to EHR documentation templates and tools. Identify what IT systems will be impacted and contact vendors to determine their plan for system readiness. Explore the full impact, such as whether there is a cost associated with necessary upgrades.  Keep in mind the E/M changes apply only to office and other outpatient visits so confirm the EHR will continue to capture today’s documentation requirements for E/M services provided in other settings (e.g. inpatient, observation, critical care, and ED visits). Be thorough in considering documentation processes. The assessment should identify any forms or templates that may need revision. When assessing documentation, focus on capturing elements required for medical decision making (MDM) and documenting total time spent.

Step 3: Conduct a Financial Assessment

The E/M Implementation Task Force (established in Step 1) should use insights gleaned throughout the impact assessment (i.e. Step 2) to identify activities and tactics that will be necessary to ensure a smooth transition. Task Force members should also begin to determine the estimated cost and priority of identified activities. The cost and priority of an activity should be assessed in light of the expected return on investment. For example, it would be extremely important to address a documentation gap on MDM components that resulted in a significant left shift in E/M levels since that would have a significantly negative financial impact. Compile and organize this information to conduct a financial assessment, set financial priorities and begin to create a proposed transition budget.  Some costs to consider include software modifications/upgrades, the number of staff who will need education and what type of education is needed, and E/M coding audits pre- and post-implementation.

Step 4: Develop Communication and Training Plans

Change management is an important aspect of a successful transition. Communication should be provided on a regular basis throughout the implementation to help ensure a smooth transition and reduce anxiety and resistance. Initial communication should provide general information to create awareness regarding the changes, expected benefits, potential challenges and an outline of the implementation plan. Again, the size and complexity of the organization will determine the scope of the communication plan. Analyze organizational departments or groups and identify key messages for each group.  For example, executive level staff likely don’t need to know detailed training agendas, rather they may want an outline of the planned role-based training. In contrast, professional coders will be interested in a detailed roadmap of the training and education plan offered to them.

The Task Force should determine role-based training requirements based on the E/M code knowledge necessary to carry out a particular role or job. These training requirements will determine what training should be developed and to whom it should be delivered. For example, the training plan for professional coders will be impacted based on their responsibility for assigning or validating office or other outpatient visit E/M codes. The Task Force should also determine the most cost-effective method of providing education. Training methods may include traditional face-to-face classroom teaching, audio conferences, self-directed learning programs, web-based instruction (self-directed or instructor-led), and/or a combination of these methods. Also determine whether training will be provided through internal or external mechanisms, or a combination of both.

Step 5: Conduct Implementation Activities and Reassess

Carry out activities according to the implementation plan while continually assessing effectiveness and revising the plan as needed. An iterative Plan-Do-Check-Act type of approach will be important to enable continuous improvement and ensure the transition is successful. After reviewing and revising documentation templates for example, perform additional provider sample audits to measure incremental documentation changes and make further adjustments to documentation tools if the desired results are not achieved.

Step 6: Internal Policy and Procedure Review/Revision

Last, but not least, a successful transition to the FY2021 CPT* E/M codes should include a thorough review and revision of internal policies and procedures related to E/M code assignment. Internal policies and procedures must be revised to address the different documentation requirements for office visit E/M codes from E/M codes for other settings. It may also be necessary to update policies and procedures to address payer-specific E/M code requirements. Also review compliance plans and make any necessary revisions.  Of note, the FY21 E/M guidelines require a “medically appropriate” history and/or examination on each office or other outpatient visit. For these E/M codes, the history and exam components are no longer an element in selection of the visit level so there are no explicit documentation requirements. The organization should consider how to leverage this change to lessen the documentation burden for providers, yet still record the information needed for continuity of care. Policies will need to be revised accordingly.

Start Now, Don’t Delay

By Q3 2020, healthcare organizations should have conducted comprehensive assessments and should be carrying out planned implementation activities. If you have not yet performed a dual E/M coding analysis, applying the FY21 E/M codes and guidelines to a sample of office visits, contact UASI today for cost-effective assistance. January 1st is fast approaching, make sure you are on the right path for a successful transition to the FY21 CPT* E/M code changes.

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