Although changes to the guidelines for evaluation and management (E/M) codes don’t begin until 2021, understanding these changes and educating practice stakeholders about them is essential. Here is a summary of the key changes to expect starting on January 1, 2021.


CMS is making E/M coding and documentation changes to reduce administrative burden and decrease the need for audits. These changes simplify documentation requirements for exams. In making these changes, CMS is focusing on clinically relevant exams and histories, using medical decision-making as the driving factor to determine the level of service. The current 1997 E/M guidelines will be replaced by the 2021 revisions for office-based and other outpatient services.


A “medically appropriate history and/or examination” should be documented in lieu of the previously required history and examination elements. Under the new rules, an E/M code will be selected based on level of medical decision-making (MDM) or total time. Total time is defined as the total time the physician spent on the case on the date of service provided. The three categories for MDM will be updated with more specific definitions.

The level 1 new patient CPT code 99201 will be eliminated. New patient codes for levels 2 through 5 will remain (CPT 99202-99205) as will the five existing established E/M codes (CPT 99211-99215).

A series of shorter prolonged-service codes will be implemented. These codes will capture physician time in 15-minute increments and can be reported only with CPT codes 99205 and 99215. Prolonged-service codes can be used only when total time is the primary basis for code selection.


For services for which the place of service is assisted living facility, skilled nursing facility, nursing home, emergency department, or inpatient hospital service, the E/M documentation requirement will not change. This would apply, for example, to an inpatient encounter for retinopathy of prematurity. Table 1 lists the appropriate place-of-service codes not affected by the 2021 revisions to E/M codes.


Medical Decision-Making

Beginning in 2021, regardless of place of service, all E/M codes will use the newly defined MDM criteria. The three categories for determining MDM level—number of problems, amount and/or complexity of data, and table of risk—will remain. However, these elements have expanded definitions, added examples, and ambiguous terms removed. Table 2 provides a comparison of MDM category definitions from the current and future schemes.

Total Time

In 2021, time may be used to select the level of E/M service for office-based or other outpatient services, even if counseling or coordination of care does not dominate the encounter. This is a change from the 1997 guidelines.

When using total time to determine the level of E/M service, include the face-to-face time spent by the retina specialist. Activities performed by the physician preparing to see the patient the same day would count toward total time and should be documented. These may include communication with the referring physician and ordering tests, for example. Time that the clinical staff spends with the patient should not be included. Tables 3 and 4 outline the differences between the current and future guidelines.

Accurate chart documentation is imperative when calculating total time for E/M code selection. For those using paper charts, document the total physician time for the encounter. In an electronic health record, date stamp the initiation and conclusion of the physician face-to-face time with the patient. This documentation will be necessary in the event of an audit.

Start preparing for this transition by reviewing your paper chart notes or electronic health record templates for any necessary changes due to changes to E/M coding guidelines, including the history and examination elements.

Prolonged Services

The revised guidelines include prolonged-service codes for patients who require additional time with a physician. The new prolonged codes will be used only in an office-based or outpatient setting when total time is calculated, and only with level 5 new patient CPT code 99205 or established patient CPT code 99215.

The prolonged codes will be in increments of 15 minutes when total time for a new patient encounter is at least 75 minutes, or for an established patient visit is at least 55 minutes. Tables 5 and 6 reflect the levels of prolonged services for new and established patients, respectively, and outline a placeholder code (eg, 99XXX) that will be replaced with a permanent code in 2021.


As currently configured, E/M codes will be associated with increased reimbursement in 2021. Although this is good news for these services, the adjustment as proposed is budget-neutral and will reduce the allowable for other services such as intravitreal injection, laser application, surgery, and testing services. Increased reimbursement will not include eye visit codes.

The E/M code increase proposal will not be applied to underlying postoperative visits that are a part of global surgery packages. These changes will affect reimbursement for surgical codes next year. The AAO and other organizations continue to lobby for the E/M increase to include postoperative visits, which are an inherent part of the surgical code.

On a positive note, as of January 1, 2020, ophthalmologists are excluded from the total per capita cost (also called TPCC) measure in the Merit-Based Incentive Payment System (also called MIPS) cost formula. Previously, some providers may have used eye visit codes to avoid reaching the 20-patient case minimum for this measure when reporting E/M codes. Under this revision, using E/M codes will not affect MIPS TPCC cost.


Although these E/M revisions will not begin until 2021, it will take significant time and ongoing education to implement these changes within your practice. AAO resources are available, and future Retina Today articles will explore the use of these guidelines in daily practice. This is the first change to E/M guidelines since 1997, and successful implementation will require a commitment to embrace this paradigm shift.

Conquering the New E/M Documentations Guidelines for Ophthalmology is available at For additional retina practice management and coding updates, visit