Documenting the E/M Outpatient Visit

As you have trained, researched, debated and questioned how to use the 2021 E/M Guidelines, what are the key changes you plan to train your providers on?

One of our expert auditors, Jill Young, CEMA, CPC, CEDC, CIMC has suggested that a narrative note could be very effective to a) tell the story of the patient, b) be concise and clinical, documenting and showing the intensity of care considered and provided and c) justify medical necessity of the level of service provided.

Thomas Robey, MD, PhD in his article “The Art of Writing Patient Record Notes”  in July 2011 edition of the AMA Journal of Ethics says:

“Do you remember the last time you read an excellent physician note? If it was similar to any of the gems I’ve discovered, it was well organized and included the pertinent data from the encounter, all the while keeping the patient at the center of the dialogue. Good notes facilitate continuity of care, since many physicians gather background information in the electronic medical record (EMR) prior to meeting a new patient.”

As one of our event participants stated, the 2021 E/M coding guidelines can be supported by a return to documenting as a SOAP note. To support outpatient E/M services, the note should document the intensity of service, the intensity of assessment and treatment plan.

There are a myriad of articles on the topic of writing good visit notes. There is also a growing interest by patients and caregivers to be involved in their care.

So how should you educate your providers to write their notes in today’s world of patient portals and provider / patient communication?

Here is one commentary by Jared W. Klein, MD, MPH, et al in The American Journal of Medicine, Vol 129, No 10, October 2016.

  • Be clear and succinct
  • Directly and respectfully address concerns
  • Use supportive language
  • Include patients in the note-writing process
  • Encourage all patients to read their notes
  • Ask for and utilize feedback
  • Be familiar with how to amend notes

Hannah Chimowitz and Leonor Fernandez, MD, recommend in their article “Sharing Visit Notes: Getting Patients and Physicians on the Same Page” in AAFP’s Family Practice Management. 2016 Nov-Dec;23(6):10-13.

  • Be transparent.
  • Minimize jargon and abbreviations, especially any that patients might easily misinterpret.
  • Briefly define or simplify medical terms, such as short of breath, rather than SOB or dyspneic.
  • Highlight the patient’s strengths and achievements in addition to his or her symptoms.
  • Describe behaviors

Additional guidance may be found on your MAC’s website. Here are some documentation tips from WPS GHA. In their introduction of documentation tips for E/M coding, WPS GHA reminds the reader (bold font is theirs) “Evaluation and Management (E/M) Services Documentation must support the level of service billed and the medical necessity for the level billed.“

Medicare requires a face-to-face encounter with a patient consisting of elements of both evaluation and management.

The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient.

The management portion is substantiated when the record demonstrates an influence on patient care (ex.; medical decision making, patient education, etc.).

Novitas provides the following FAQ to the question about documenting history and exam.

8. Is the documentation of history and examination required when scoring office/outpatient services under the revised 2021 guidelines?

The approved revisions do not materially change the three current MDM elements, but instead provide extensive edits to the elements for code selection and revised or created numerous clarifying definitions in the E/M guidelines.

While the provider’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.

The revised code descriptors state a “medically appropriate history and/or examination” is required.

An additional benefit to a clear note that supports the medical necessity for the service – is that it can help to improve coding the encounter – whether you are new to the field of coding or a highly experienced auditor. 

What are your thoughts on using this type of encounter documentation?

What other documentation methods might be useful?

What about the definition for “Problem Addressed or Managed”?

Our goal in this blog series is to provide a forum regarding topics around the 2021 E/M Guidelines and to encourage community conversation on how the new guidelines might be applied. We’ll provide scenarios and expert opinion for your consideration, and we hope you’ll feel free to contribute to the thoughts and ideas presented by fellow auditors, coders, billers, CDI professionals, compliance professionals, payment integrity and risk managers.

The AMA has provided a definition for “Problem addressed” in the 2021 AMA CPT(R) Manual.

“Problem addressed: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice.”

More importantly, the definition includes this statement.

“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.”

Many EHR patient records systems automatically pull the patient’s “problem list” and their complete “medication list” into a new encounter. This information may not be considered in the EHR’s 2021 guidelines unless notation is made about an evaluation or treatment of the problem(s), additional assessment needed or care coordination of the issue.

Though the new encounter may have a complete “problem list,” sufficient documentation is needed to note which problem(s) affects the MDM for the encounter, and what the risk of morbidity is. In a list of problems or multiple providers, which problem(s) are being managed by the provider during the encounter?

The medication list is another area that could draw questions. Experts recommend there should be notes indicating who is managing which medications in the case of multiple providers managing care. Specifically, it is best to show which medication is being managed by the physician for the encounter. The statement “continue meds” is not a sufficient indication of management.

Taken together, these elements may impact the risk associated with the care provided by the provider to manage the patient’s condition(s). These elements support the basis for the level of service provided during the encounter and the E/M code billed.

Is your provider’s documentation clear enough to note the problems addressed and the intensity of service provided in the encounter?

What types of changes would you recommend to the provider?

Documenting Medical Necessity

If you do a google search regarding medical necessity for E/M coding, you will find many articles, many experts referencing CMS guidance to Medicare payers in CMS’ Medicare Claims Processing Manual. The often referenced section is summarized as follows:

30.6.1 – Selection of Level of Evaluation and Management Service
(Rev. 3315, Issued: 08-06-15, Effective: 01-01-16, Implementation: 01-04-16)

A. Use of CPT Codes
…. The service provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices. …

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

B. Selection of Level of Evaluation and Management Service
Instruct physicians to select the code for the service based upon the content of the service.

Here is the reference from the CMS’ Medicare Claims Processing Manual.



From 1995 to 2020, many coding educators trained providers to document the 3 Key Components of history, exam, and medical decision making. These components provided some context to document medical necessity when used appropriately.

With the activation of the 2021 EM Outpatient coding changes as of January 1, 2021, clearly documenting the medical necessity of an outpatient E/M visit is just as important. We have heard from clinicians that the 2021 EM coding guidelines will be more familiar and consistent with the way they practice.

However, many EMR records now carry ICD-10 codes for MIPS purposes and to “tell the story” of the health of the patient. Though a provider may not be managing all of the conditions, some conditions outside of their care may enter into the risk and complexity of the conditions the provider is managing.

The new 2021 E/M Guidelines focus on medical decision making as it relates to the care the provider is providing to the patient’s condition(s). Providers will need to document to support billing, as well as to be clear if reviewed by an outside reviewer in the future.

Here are some thoughts to consider.

How are you training your providers to clearly document what is to be billed and what conditions, though not billed, impact the risk and complexity of the provider’s care of the patient?

Does your encounter note clearly delineate between notes taken by MA for non-billed ICD-10s, and notes by the provider referring to conditions that impact the management of patient care?

Should I use Data to be Reviewed and Analyzed: Minimal or None?

This week’s question: “Could you please explain what the Minimal Data to be Reviewed check box would be used for? In what instances would we use this?”

The AMA’s Data to be Reviewed and Analyzed column lists “Minimal or none”  as part of the definition for a Straightforward MDM.

A Straightfoward MDM defines the lowest E/M code level a provider will be coded – an E/M code “level 2” – 99202 or 99212.

Whatever “cheat sheet,” software, checklist you are using, coding an E/M code using “no data reviewed or analyzed” seems counter intuitive and may be difficult to defend.

If we look at the pre-2021 (1995 / 1997) MDM’s Data to be Reviewed and Analyzed – it also lists tests, old records, external sources, etc.

AMA – E/M Office Visit 2021

Slides 50 says

MDM: Amount and/or Complexity of Data to be Reviewed and Analyzed

• Simplified and standardized contractor scoring guidelines

• Emphasized clinically important activities over number of documents

• Need to account for quantity of documents ordered/reviewed (as it is MDM work)

Note that the goal for the Data to be Reviewed and Analyzed section is meant to quantify its impact on the effort in medical decision making (“it is MDM work”).

As we’ve highlighted in prior articles, having a definition for 99202 or 99212 and/or asking providers to document for complexity of diagnosis and risk of morbidity would provide a more compliant process to bill for any E/M code.

With a “grey area” such as Data To be Reviewed minimal or none, how providers are trained to document will need to be defensible in a retrospective audit review. It is best to document the methods and definitions your organization defines in your standard operating procedures.

Using Time to determine an Outpatient E/M code

Our goal in this blog series is to encourage conversation regarding open topics in the 2021 E/M Guidelines. We’re hoping to help bring clarity, to provide scenarios for your consideration, and to help you educate your providers.

The previous E/M Guidelines stated that Time may only be used when counseling and/or coordination of care dominates the service.

As of January 1, 2021, the AMA has provided new definitions on using Time to determine an E/M code. 

The 2021 AMA CPT(R) Manual states: 

“For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face tie personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).”

The exception is 99211. Per the AMA, “the time component has been removed” for 99211. The time to supervise clinical staff is not measured. The CPT(R) Manual states “… if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211.”

Although using Time to code an E/M would seem to be a welcomed change, industry thought leaders are asking “how will practices justify the E/M code billed based on Time when medical necessity is the “overarching criterion” for coding an E/M service?”

Here are the conditions outlined in the 2021 CPT(R) Manual. Bold font is our device to call attention to specific definitions. 

Expanded definition

  • includes both the face-to-face and non-face to-face time

Specific timing

  • on the day of the encounter

Specific qualifications

  • personally spent by the physician and/or other qualified health care professional(s)
  • (includes time in activities that require the physician or other qualified health care professional
  • and does not include time in activities normally performed by clinical staff ).

AMA’s 2021 CPT(R) Manual lists nine activities that can be included in defining the Total Time spent in caring for a patient. Note that these activities cover pre-encounter, intra-encounter, and post-encounter activities.

As our audit experts recommend, remember to document the medical necessity for the encounter. Also, remember that Total Time for the provider’s day should be reasonable. If an auditor were to add up all the time billed, would the total time for the day be physically possible? As we’ve noted in a prior post, auditors are looking for “potential fraud, such as claims development and submission processes, code gaming … “

In your education and planning for coding Outpatient EMs for dates of service in 2021, under what scenarios will you use Time to bill an Outpatient E/M code?

What documentation will you train your providers to do to communicate the medical necessity?