Significant changes to documentation and coding requirements for office and other outpatient evaluation and management (E/M) services were implemented in 2021. However, there is more work to be done to reduce documentation burdens and revise codes to more accurately capture the work of all E/M services, especially those that are currently selected based on key components or on intraservice time when a physician or other qualified health care professional (QHP) spends more than 50% of the intraservice (face-to-face or unit/floor) time in counseling and/or coordination of care. In this article, we will review the extensive history of the E/M documentation burdens, progress so far, and expectations for the future.

The 2021 revisions to documentation and code selection for office and other outpatient E/M codes leave many physicians still dealing with the burdens of the 1995 and 1997 guidelines for other E/M services (eg, initial and subsequent hospital care). However,...

You do not currently have access to this content.