E/M Documentation Guidelines: Are You Still Coding Under the Old Rules?

AMA's 2021 E/M coding changes were the biggest overhaul in decades — and some family medicine providers are still not capturing the full benefit.

Key reminders:

• - Medical decision-making (MDM) is now the primary driver of code level — not visit time
• - Total time (including non–face-to-face work on the date of service) can be used as an alternative
• - History and physical exam no longer set the code level — they only need to be "medically appropriate"

Undercoding E/M services because of old habits is one of the most common revenue leaks in primary care.

Have you audited your E/M distribution lately?