2021 Office and Outpatient E/M Coding and Documentation Guidelines

Quality & Practice

Code descriptors and documentation guidelines for office and outpatient evaluation and management (E/M) codes are changing effective January 1, 2021. These changes are the result of a multi-year advocacy effort.  AAPM&R was one of the participating societies that contributed to the E/M revisions and revaluation. The new guidelines are expected to reduce documentation burden and make coding selection easier. However, the changes are significant and require action on the part of physicians and their practices. 

Please note the changes are limited to office and outpatient E/M and do not apply to inpatient or SNF coding. 

How to Prepare for 2021

If you registered for AAPM&R's Annual Assembly, be sure to watch E/M in 2021 - Tips and Tricks for Coding and Documentation Under the New Guidelines on-demand. It will be available soon!

Review the AMA’s detailed summary of the changes to E/M.

Download a copy of the AMA CPT Level of Medical Decision Making Table.

Watch the coding experts who led the E/M revision process explain the new codes in a series of videos.

Learn more about the 2021 Medicare Physician Fee Schedule.