Clearing up confusion on the new E/M guidelines

Comparing the old guidance to the new.

Q: In the new 2021 Evaluation and Management (E/M) coding guidelines the AMA appears to have put most of their effort into what we’ve been calling the ‘Data Table’, the second of the current three Decision-Making Tables. This now appears to be “column 2’ of the new, single table we are supposed to use for calculating E/M code levels. This column or component seems quite busy and involves a lot of counting — do we need to address this time we see a patient?

A: This seems to be a common reaction to the reconfigured ‘Table Two’ or ‘Data Table’ Now Column Two…. And the answer is no, attaining any given level within Column 2 is not required to select the overall code in any given case. Depending on your specialty, and the circumstances of the specific encounter, you could often code rather easily without it.

Given that this table is intended to capture the work associated with gathering and processing data of all sorts:, ordering/interpreting different categories of diagnostic tests, multiple tests, review of imaging, information obtained in discussion with others etc. – those encounters that are not data-heavy will thereby have less need of this table. For primary care follow up visits, which most frequently involve periodic lab tests – this column is unlikely to influence the overall code level significantly. Or put a different way, you can code most of your chronic disease follow up visits with column 1 and Column 3 only – you only need two of the three columns to agree (meet or exceed) to support a given code ‘level’ or category.

In addition to the number and nature (stable, worsened) of problems that you have (Column 1), be certain that Column 3, risk, is also clear. For stable chronics that’s most often the treatment – continue XXmg . Stick with Column 1 and Column 3 for chronic follow ups — this will handle many of your encounters.

Check out the illustrations below to compare the Coding Guidance Between Tables 1 and 3 of the 2020 E/M MDM to the new 2021 E/M MDM Coding Guidance Using Column 1 and Column 3.

Illustration I has been the coding instruction, and billing pattern to some degree, for the last 20+ years. Now, for the first time in over 20 years there will be no ‘norm’ for EM profiles – no one knows what these new guidelines will produce in terms of coding curves or profiles by specialty.

Illustration II pretty clearly shows the movement of two stable chronics to a 99214, and one worsening problem alone to a 99214. What percentage of primary care visits is that for you? This is a big movement.

And there is no doubt that the transition from one set of guidance to this next set will change the way certain high-volume presentations are coded, or ‘quantitated’ as above.

Each provider or group should take stock of their coding ‘stance’ as the new year rolls around. Here is the big takeaway on the coding changes, those areas most generous in terms of a shift in the number of issues it takes to demonstrate moderate level decision-making or higher.

Now that Table 1 has been replaced by Column 1:

  • Two Stable chronics go to 99214 if Rx is initiated, or refilled, Or
  • Two Stable chronics go to 99214 if social determinants of health are documented.

"Not at goal" is now defined as "not stable" — thereby equivalent to worsening, exacerbated, progressing etc., and adding to those issues regarded as moderate.

Using the New Column 1 and New Column 2 info:

  • Two Stable chronics are now a 99214 if three discrete labs or tests are ordered/reviewed – regardless if there are Rx or not
  • One worsening chronic is a 99214 if there is an Rx, a surgical option, 3 labs/tests or Social Determinants of Health

Problems once associated with 99214’s can be considered 5’s if there is a decision regarding hospitalization and the problem is described as severe.

And these movements occur without Table Two or column 2. Frankly, physicians usually don’t spend much time ‘calculating’ their E/M code levels anyway, they just pick them for a wide variety of reasons (if they pick them at all). So continue that, count the problems for Column 1 and characterize them for Column 3. The picking should get easier, and the pay better too.

Bill Dacey, MHA,MBA, CPC, is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, billing, documentation, and compliance concerns for physicians. Dacey is a AAPC-certified coding instructor and has been active in physician training for more than 25 years. He can be reached at billdacey@msn.com.