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E/M Reimbursement

Practicefirst would like to notify our clients of important changes in the office/outpatient E/M visits effective Jan 1, 2021. Initially CMS had proposed to bring in a reduction in the payment variation for office/outpatient E/M visit levels by paying a single rate (also referred to as a blended rate) for levels 2 through 4 while maintaining the payment rate for level 5. However, as noted in the final rule for CY 2020, they have now decided against the blended payment.

Per CMS, for CY 2021, “We are largely aligning our Evaluation and Management (E/M) coding with changes laid out by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits, which:

  • Retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients.
  • Revise the times and medical decision-making guidelines for all the codes and requires performance of history and exam only as medically appropriate.
  • Allow clinicians to choose the E/M visit level based on either medical decision making or time.  

Practicefirst will continue to update our clients throughout the year as more information/guidance becomes available from AMA/CMS.

For Coding questions, please contact our Coding Supervisors, Vidya Baliga at and Kelly Cole at or at 716-389-3262.  

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