E/M and ICD-10 Billing Code Updates for 2021

With the year winding down, now is a good time for healthcare practices and billing companies (on behalf of their clients) to prepare for billing code changes coming in 2021. This post will focus on what’s new for evaluation and management (EM) codes and ICD-10-CM diagnosis codes.


E/M Codes in 2021


“For E/M codes in 2021, the major change is the way in which physicians ultimately select an E/M code,” says Toni Elhoms, CCS, CPC, CRC, CEO of Alpha Coding Experts, LLC in Orlando, FL. The good news? It’s a more straightforward process. The bad news? The change gives more weight to medical decision-making (MDM)—an element of code selection that physicians historically under-document. Exactly what’s going to change?

Consider the following:
  • History and physical exam will not determine the appropriate E/M code level. Instead, codes will be based on MDM or total time. Note that office visits performed via telemedicine during COVID-19 are already based on physician time spent on the date of service or MDM.
  • When selecting an E/M code based on time, physicians can include non-face-to-face services (e.g., reviewing the patient’s record or discharge summary or a call with a specialist to coordinate care).
  • MDM will be driven by the number of tasks that affect the management of the patient.
  • CPT code 99201 will be deleted.
  • Physicians will be able to report a new add-on code for prolonged office or outpatient E/M services. They can report it once every 15 minutes in addition to 99205 or 99215.

Understanding these changes is only the first step. There are also many other practice management-related tasks to perform. Elhoms urges practices mangers to do the following:

1. Determine whether E/M changes will affect office scheduling. Practices may want to consider blocking off more time for each appointment so physicians can capitalize on the true intention of these codes—to spend more time with patients and get paid for doing so.

2. Ask your EHR vendor whether it can accommodate payer-specific templates. New documentation will be based on the traditional SOAP (subjective, objective, assessment, and plan) note. However, worker’s compensation, for example, does not plan to implement the E/M changes in 2021, says Elhoms. Inpatient E/M codes aren’t subject to the changes either. This means the 1995 and 1997 E/M documentation guidelines will still apply to these types of claims, she adds.

3. Identify ways to provide physician training. Will the practice rely on an external consultant? Webinars? Online courses? Making sure physicians understand these changes is paramount, says Elhoms. Time is of the essence particularly because physicians won’t be able to continue relying on the code calculators currently embedded within many EHRs. Although these calculators can count the number of systems reviewed, they can’t calculate MDM, making it important for physicians to understand the coding logic and work more closely with a certified medical coder to validate code selection, she adds.

4. Review physician contracts carefully. Although relative value units for certain CPT codes will decrease, E/M payments will increase in 2021, Elhoms. Practices need to make sure all their payer contracts reflect these higher rates, she adds.

5. Plan for audits. Practices should plan to audit as soon as possible after the E/M changes take effect to avoid costly recoupments, says Elhoms. What will auditors be looking for? Low-hanging fruit—particularly physicians Elhoms characterizes as ‘habitual time-based billers.’ These are physicians who bill based on time without any supporting documentation of medical necessity. These physicians also tend to inflate the number of patients they see—an easy error forauditors to spot. She provides the example of a physician who sees 35 patients a day, spending 45 minutes with each one, equating to approximately 26 hours of a work in a 24-hour day.


ICD-10 diagnosis codes for 2021


Regarding ICD-10 diagnosis codes, Elhoms says practices should pay attention to these changes for 2021:

Substance abuse. New codes include details related to withdrawal and complications. For example, F10.132 denotes alcohol abuse with withdrawal with perceptual disturbance. F11.13 denotes opioid abuse with withdrawal. F12.13 denotes cannabis abuse with withdrawal. F13.131 denotes sedative, hypnotic or anxiolytic abuse with withdrawal delirium.

Rheumatoid arthritis. New codes now include etiology. For example, M05.7A denotes rheumatoid arthritis with rheumatoid factor of other-specified site. M08.2A denotes juvenile rheumatoid arthritis with systemic onset, other-specified site.

Headaches. Code R51 is deleted and replaced by these two codes:
  • R51.0 Headache with orthostatic component, not elsewhere classified
  • R51.9 Headache, unspecified

Adverse effects. There are new expanded codes for synthetic narcotics:
  • T40.495A Adverse effect of other synthetic narcotics, initial encounter
  • T40.495D Adverse effect of other synthetic narcotics, subsequent encounter
  • T40.495S Adverse effect of other synthetic narcotics, sequela

Chronic kidney disease (CKD). Code N18.3 (CKD, stage 3) is deleted and replaced by the following:
  • N18.30 CKD, stage 3 unspecified
  • N18.31 CKD, stage 3a
  • N18.32 CKD, stage 3b

To help with understanding the changes, review the code changes and visit the CMS website for more information; purchase 2021 ICD-10-CM coding manuals that include code updates and revisions; and lastly, update any paper-based encounter forms or cheat sheets to reflect new and revised codes.

These billing codes updates, in addition to what healthcare practices need to know to get paid in 2021, will be discussed in Kareo’s upcoming webinar on Wednesday, December 9. Save your seat to Getting Paid in 2021: New Year, Fresh Perspective, More Revenue by clicking here.

About the Author

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a...

Subscribe to Our Newsletter!

Enter your email address to receive "Go Practice" as an email newsletter.

Free White Paper

Getting Paid in 2020: What Independent Medical Practices Need to Know

Here's a quick overview of changes in CMS programs, insurance plans and patient payments.