2021 E/M Guideline Changes: Otolaryngology

2021 E/M Guideline Changes: Otolaryngology

Educate your providers on new documentation requirements for office visits.

You’ve likely heard about the major evaluation and management (E/M) guideline changes coming in 2021. And you may be aware of the coordinating CPT® code changes, which will allow you to base E/M levels on either a provider’s time or medical decision making (MDM). The Centers for Medicare & Medicaid Services (CMS) has redefined both time and MDM to make documentation requirements clearer, but the definitions take some explaining. In the AAPC webinar 2021 E/M Guideline Changes: Otolaryngology, Jaci Kipreos, CPC, COC, CPMA, CPC-I, CEMC, makes sense of it all.

History and Exam Are Not Things of the Past

History and exam will no longer be key components for code selection. However, CMS is adding a requirement that a medically appropriate history and exam should be documented. Revised code descriptors will include the phrase “which requires a medically appropriate history and/or exam” to reflect this change. Providers should determine what is medically necessary on a case-by-case basis and document accordingly.

Remember: Providers already need only document what has changed since the last encounter, based on the 2019 and 2020 CMS final rules. Therefore, “We need to be clear on what’s old information and what’s new information for the date of service,” Kipreos says.

When Time Is the Determining Factor

In the 2020 Medicare Physician Fee Schedule (MPFS) final rule, CMS proposes to redefine time from face-to-face time to total time spent on the day of the encounter. This may include:

  • Preparing to see the patient (e.g., review of tests)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate exam and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Documenting clinical information in the medical record
  • Independently interpreting results and communication results to the patient/family/caregiver
  • Care coordination

“There’s no indication in the final rule that time must be itemized,” says Kipreos. She expects that CMS will clarify what it wants to see in the documentation in the 2021 MPFS proposed rule (not yet released when this article was written).

The challenge will be to get providers to track their time with each patient as well as time spent determining and executing care. “Intro-duce this thought process to your provider now,” Kipreos advises.

Kipreos recommends providers begin tracking how much face-to-face and non-face-to-face time they spend on each patient, on average. This will help them to determine whether it is generally more appropriate for them to code based on time or MDM.

When MDM Is the Determining Factor

When coding based on MDM, Kipreos says you will need to assess three MDM elements, which will be revised as follows effective
Jan. 1, 2021:

  • “Risk of complications and/or morbidity or mortality” will be changed to “Risk of complications and/or morbidity or mortality of patient management.”
  • “Number of diagnoses or management options” will become “Number and complexity of problems addressed.”
  • “Amount and/or complexity of data to be reviewed” will be changed to “Amount and/or complexity of data to be reviewed and analyzed.”

Remember: A diagnosis does not determine the complexity of risk, CMS points out. When considering the number and complexity of problems addressed, coders must also examine how extensive the evaluation was and whether multiple lower-severity problems collectively create a higher risk due to interaction. Kipreos goes on to explain that “a part of these guidelines is to be able to account for all the work that goes into the final diagnosis, into the management of the patient.”

Comorbidities/underlying diseases are not considered in the E/M code level unless the provider takes them into consideration in the management of the patient. To count toward level of service, the documentation must indicate that these conditions are being addressed, and in doing so, will affect what is being ordered, or they will complicate the management.

CMS says in the 2020 MPFS final rule, “A problem is addressed or managed when it is evaluated or treated at the encounter … Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service.” A referral without evaluation or consideration of treatment does not qualify as being addressed or managed either, CMS further states.

“They’re using two separate words, so really think about that. Something can be ‘addressed’ even though it’s not managed by your provider,” Kipreos points out.

Kipreos suggests, “Step back and think: Is your provider truly giving that information in their documentation to clarify how hard they’re thinking today?”

Currently, Kipreos explains, your provider can order 10 different lab tests and only get credit for one. This will change in 2021. The definition of data has been expanded so that each test, as defined by a separate CPT® or HCPCS Level II code, will count toward the level of risk.

Risk, the third thing that counts toward MDM, is the probability and/or consequence of an event. The provider must ask:

           What would happen if I do this?

           What would happen if I don’t do this?

Providers will begin receiving credit for documenting social determinants of health (SDOH) such as food or housing insecurities. These factors, which may affect risk level and patient care, are reported with ICD-10-CM codes Z55-Z65.

Drug therapy, another element of risk, is further defined to help us understand documentation requirements. When a provider initiates management with a drug, they should document any adverse effects to the therapy that require monitoring. Providers must specify the justification for monitoring in the documentation. “They’re not looking to see if the drug is working,” Kipreos explains. They’re looking for adverse effects. “It needs to be very clear in the documentation that there will be monitoring and why.”

Add-On Codes for Additional Work

Proposed HCPCS Level II code GPCIX will be an add-on code for reporting encounters that require more work than what is described in the CPT® codes. “Think of it like as if we could put a 22 modifier on an E/M code, which we can’t,” Kipreos says. This new code is meant to be used when a provider has gone above and beyond managing the ongoing care of a complex patient with serious or complex issues. Stay tuned for more information associated with this code. The 2021 final rule should provide further definition and examples on how we will use this new add-on code, Kipreos believes.

Clinical Documentation Improvement

Providers will need to continue working on improving their documentation to support the new E/M coding guidelines. Educate your providers to:

  • Communicate the complexity of the patient’s condition
  • Provide a clear assessment and plan
  • Indicate the number of tests being ordered, with rationales
  • Include documentation for interpretations, when performed
  • Continue to document clinically appropriate histories and exams

Kipreos provides several code cases in her webinar to help coders make sense of all the E/M guideline and coding changes. Coding Case 1 below provides an example.

Coding Case 1

Can you code this case based on 2021 coding guidelines?

He is here with severe nasal congestion, drainage, and a sore throat. Has had a cough. Thought he had the flu about 2 weeks ago. Stayed in bed for 5 days. Had a high fever and that is when the cough started. Fever went down. Thought he was feeling better, and then he started coughing and now it keeps him awake. Has a history of hypertension and has to watch his heart rate. Has had an MI and stent placement. He is a regular patient of Dr. X. Did have the flu and pneumonia vaccines. Nonsmoker. Pain is 0 on scale, with 0 being no pain and 10 being the worst. No vomiting or diarrhea. No history of asthma. ROS remaining are negative.


  • Penicillin  
  • Sulfa  
  • Cholesterol tabs
  • Cipro. Had to take Cipro for a long period of time for a urinary tract condition, and he developed an adverse reaction to it. Has had Levaquin since then and has done okay. His mother is allergic to Cipro.


1. Xanax  2. Ambien  3. Prevacid  4. Metoprolol  5. Aspirin

Temp: 97.3, P: 74, R: 20, BP: 120/74, WT: 198, HT: 68.

61-year-old awake, alert, and in no apparent acute distress right now. HEENT: Eyes: Clear, no redness or drainage. Ears: TMs dull. Landmarks barely visible. Nose: Nasal membranes extremely erythematous. Maxillary and frontal sinuses: Tender and puffy. Throat: Erythematous, no exudate. Uvula midline. Neck: Supple. No palpable lymphadenopathy. Chest: Coarse bronchial sounds over anterior chest. Posterior, no basilar rales. Heart: RRR. Abdomen: Soft.

Chest X-ray: The heart and mediastinum are normal. No lymphadenopathy is seen. The lung fields are clear.


1. Acute sinusitis  2. Postnasal drip  3. Acute bronchitis


  • I have prescribed him an inhaler before. Gave him an Albuterol inhaler 12 puffs q 4-6 hours, prn #1, no refills.
  • Should be able to use Guaifenesin 600 refills.
  • Levaquin 500 mg 1 q day times 10.
  • Rocephin 1 gm IM now.
  • Increase fluids.
  • Diet as tolerated.
  • Schedule a follow-up appointment with Dr. X, especially if symptoms worsen or he is not doing well.
  • He was receptive to these suggestions.
  • No communication barriers.
  • Questions were answered to the best of my ability and to his reported satisfaction.

See Table 1 and Table 2 for the codes. Watch the webinar for the answers.

Table 1: Coding for time

Table 2: Coding for MDM


Renee Dustman, BS, AAPC MACRA Proficient, is a senior development editor for AAPC. She is a member of the Flower City Professional Coders local chapter in Rochester, N.Y.

Stacy Chaplain, MD, CPC, is a development editor at AAPC. She has worked in medicine for almost 20 years and has more than five years of experience in medical writing and editing. Chaplain received her Bachelor of Arts in biology from The University of Texas at Austin and her Medical Doctorate from The University of Texas Medical Branch in Galveston. She is a member of the Beaverton, Ore., local chapter.




Certified ENT Coder CENTC

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