For over 20 years the same guideline requirements have been used to determine the level of service for office and outpatient visits. Providers had concerns that these guidelines required some elements that were not necessary from a clinical perspective, not to mention the time it takes to document each visit. The Patients Over Paperwork Act joined together the Center for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) to create new guidelines that allowed providers to spend less time documenting and more time administering quality care to patients. The new guidelines streamline the documentation for history and examination to only what is pertinent to that visit, allowing the level of service to be determined by time or medical decision making. These new choices allow providers to use them on a patient by patient basis for more flexibility in the documentation. Although these choices have been previously used, the requirements have been updated to meet the expectations of these visits in today’s medical practice. Because these guidelines are in the CPT® 2021, unless otherwise noted by the insurance company, these documentation guidelines will apply to all insurance companies.

Webinar Objectives

Because these documentation guidelines will be required on January 1, 2021, all providers and staff that are involved with office and outpatient visits should be aware of the changes. Also, electronic medical records system templates will need to be updated to accommodate the new elements for documentation. This webinar by E/M expert Lynn M. Anderanin will review all the necessary elements for the choices of time and medical decision making for attendees to walk away with the understanding of how to choose the level of service based on the new documentation requirements.


Webinar Agenda
  • New and revised CPT® codes for office and outpatient services
  • Medicare Physicians Fee Schedule Final Rule 
  • What services are included when using the time to determine the visit level
  • Changes that have been made to medical decision making and the table of risk
  • Forecasting how the new documentation guidelines will affect revenue for visits

Webinar Highlights
  • The new role history and examination will play in visits
  • The elements that make up the time option for documentation
  • How the diagnoses codes play a role in medical decision making
  • Improved ways to count diagnostic tests for data
  • Additions to the table of risk for higher levels of service
  • New vs established patients under these changes
  • New concerns from outside auditing by insurance carriers

Who Should Attend?
  • Physicians
  • Advanced Practice Nurses
  • Nurse Practitioners
  • Biller
  • Coder
  • Auditor
  • Claims Processor
  • Collector 
  • Reimbursement Specialist
  • Claims Adjuster