In January 2021, the most significant revisions to the guidelines for evaluation and management (E/M) codes since 1997 will be implemented.
These changes will impact your electronic health record (EHR) and practice management (PM) systems, and identifying the implementation timeline is crucial. Initiate discussions with vendors regarding any revisions to software functionality and identify their solutions for key E/M changes.

Use the E/M Transition: EHR and PM Checklist for your discussions:

• EHR template updates — Will your templates need to be revised for a medically relevant history and examination based on the 2021 E/M guidelines? Will your review of systems need revisions for an ophthalmology relevant review of systems?
• Documentation of “total time” — Identify how the EHR system will record the total time spent with the patient for the date of service when time is the determining factor for E/M code selection. The physician time for both the face-to-face encounter and performing other activities (e.g., ordering medications, communicating with the referral provider) should be included in the EHR documentation. Identifying software solutions to streamline this process will be beneficial as an alternative to manual tracking and data entry.
• Automated E/M coding software solutions — If you utilize a coding software system that analyzes documentation and automatically determines the E/M code selection, discuss the timeline for software updates. These changes should include how the software will accurately assess the medical decision-making (MDM) or total time based on discreet data or narratives.
• Elimination of CPT code 99201 — With the deletion of CPT code 99201 on Jan. 1, 2021, both paper and electronic superbills will need to be updated. EHR and/or PM systems may require inactivating 99201 from procedure libraries and drop drown lists.
• Third party software — Confirm with third-party software vendors if any of the E/M changes will impact their systems. These vendors may include your clearinghouse, patient portal, eligibility verifications, and recall systems.
• Software and hardware upgrade — Determine if a software and hardware system upgrade is necessary for E/M compliance. Determine when the updated software will be available and schedule the upgrade. Identify any hardware system specifications required for the new software.
• Develop new workflows and train — If your EHR and PM system has software functionality updates that affect internal workflows, identify and create new protocols. Once completed, schedule training sessions for staff and physicians on the new process.

For a comprehensive review of all the 2021 E/M documentation guidelines, explore Conquering New E/M Documentation Guidelines for Ophthalmology and visit aao.org/em.