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2021 Office and Outpatient E/M Coding and Documentation Guidelines

Quality & Practice

On January 1, 2021, code descriptors and documentation guidelines for office and outpatient evaluation and management (E/M) codes changed. This major coding overhaul reflects the most substantial updates to E/M since the mid-1990s.

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.

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

Under the new guidelines, code selection is now based on either medical decision making or time. History and physical exam will still be documented, but not a part of the code selection process.

Given the significant nature of these changes, AAPM&R is offering members complimentary access to our 2020 Annual Assembly session on E/M in 2021.

2021 E/M Coding Resources

  • 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.
  • Didn't get a chance to register for #AAPMR20? AAPM&R members can access the E/M in 2021 - Tips and Tricks for Coding and Documentation Under the New Guidelines recording on our Online Learning Portal.

Watch the video clips below for a sneak peek at this session: