Evaluation and Management (E/M) Coding: The 2021 Changes

Contact Terri Scales:  ts@billdunbar.com

Modernizing healthcare has been the driving force behind several changes in the medical field. One such change that medical professionals across the globe must adapt to is the 2021 update in Evaluation and Management (EM) Coding. Changes in EM Coding can impact the operation of an entire healthcare practice, from medical record keeping to insurance billing. Therefore, understanding these updates can be of immense benefit for healthcare providers.

Availing the Benefits of NAOHP events

NAOHP (National Association of Occupational Health Professionals) events provide platforms for healthcare professionals to understand new developments in the industry. These virtual events are a burgeoning source of learning, fostering an environment for knowledge sharing among peers.

The highlighted event featured Dr. Larry Earl sharing insights on the latest Evaluation and Management (EM) Coding updates for 2021. He hosts these virtual events to enlighten healthcare providers about new platforms and their functionalities. NAOHP also invites expert guests to these events. For this particular session, Terry Scales from Bill Dunbar and Associates (BDA) was the guest expert who elaborated on the coding updates.

Preparing for the Changes in EM Coding

Terry Scales, a double certified professional coder, shed light on the changes in EM Coding. The updates implemented on January 1, 2021, have focused on office-based and outpatient visit codes. The crucial change has been that the level of coding and the subsequent billing is now primarily determined based on medical decision making or the overall time spent by the medical professional. This approach replaces the previously mandated extensive documentation of history and examinations.

To understand the changes, Terry offered the following advice:

  • Review Your Current Documentation: Carry out a comparison of your current documentation practices with the revised EM Coding guidelines. This shows your current alignment and readiness with the new guidelines and helps identify areas needing improvement.
  • Understand the New Elements: The 2021 EM Coding updates have introduced the concept of three distinct elements for choosing the correct level of service. These include the number and complexity of problems, the amount and complexity of data to be reviewed, and the risks of complications or morbidity.
  • Be Aware of the Unchanged: Quite a lot in your current documentation practice remains unchanged. This includes your referral procedures, diagnosis codes, use of modifiers, and so on. Hence, while updating your practices, it helps to know what remains the same.
  • Print the AMA Guidelines: The AMA (American Medical Association) provides guidelines to help medical professionals manage the changes. Print this guide and keep it in your consultation room for easy access.


The changes to Evaluation and Management Coding are an essential evolution and understanding them is vital for efficient healthcare practice. NAOHP events and other such platforms offer valuable insights on adapting to these changes. Through understanding and implementing these changes, healthcare providers can continue providing excellent services while ensuring streamlined operations.

Thank You To Our Annual Sponsors

Join Our Network of Occupational Health Professionals