Coding and Billing

The Solution to Billing Successfully Under the New CMS E/M Coding Guidelines

By James E. Grue, OD,
and Ronald P. Snyder, OD, FAAO

Jan. 6, 2021

The Centers for Medicare & Medicaid Services (CMS) finalized new E/M requirements, which became effective on January 1, 2021. This new rule reduces the burden on providers imposed by the old coding system and rewards time spent evaluating and managing patient care. Here are the details about this change, and what it means for your coding and billing procedures.

What Exactly Changes for Me?
For those providers who are utilizing a registry, a unique situation now exists that will likely allow you to bill at a higher level under the new E/M code requirements. The changes to the E/M coding requirement are one of the final steps in moving from fee-for-service to a patient-centered outcome-based delivery system. The new coding guidelines are designed to support outcome-based patient-centered care that is being put in place through health-care reform.

The simple reality is that, if you continue to deliver care the way you have in the past, you can expect a decrease in income and increased difficulty meeting the coding guidelines. To better understand how the new coding requirements apply, let’s use, as an example, the eye exam for 67-year-old Medicare patient who has been diabetic for six years. The examination did not real reveal any visible retinopathy or any other significant ocular conditions.

The following is a summary of the activities on which the new E/M Coding Guidelines based reimbursement:
1) Properly completing and documenting tests related to the patient’s problem(s)
2) The number and complexity of problems addressed
3) Amount and/or complexity of data to be reviewed and analyzed
4) Risk of complications and or morbidity or mortality
5) Complexity of care coordination

What Are the Advantages of the New E/M Coding Guidelines?
These new guidelines reimburse you better for doing completely different activities than the type of exam driven by the old guidelines. The new guidelines take into consideration today’s powerful new technologies that affect virtually every other part of our lives, but haven’t been incorporated into medicine. The new guidelines now reimburse you for using these new technologies. Conversely, they will lower the reimbursements for providers that decide to continue to deliver care that does not incorporate them. The reason is simple. When these new technologies are used in the delivery of medicine, they benefit patients and result in better care delivery, just as they improve virtually every other aspect of our lives.

Today, new technology exists that makes it easy to share patient health information and data. Being able to share data within medicine makes it possible for providers to work together as teams. The second important technology is big data analytics, which makes it possible to analyze the care being delivered in ways that provide whole new insights into the results of the care for which the payers are paying.

The new E/M guidelines reward providers for using these new technologies, which were not available at the time the older coding guidelines were put in place. Using them makes it easier for a provider to understand the complexity of the care being provided, and to better understand the risks to the patient. These same technologies provide the ability to coordinate the treatment plan with the providers that make up the care team.

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How the New Guidelines Will Play Out
Let’s look at how these new guidelines apply to the coding a Medicare exam on a 67-year-old male who has been diabetic for six years, has no other significant ocular findings and does not have any diabetic retinopathy.

With the new guidelines, the number and complexity of problems addressed is an important component of the billing. Instead of questioning the patient, you will get more accurate information by obtaining the patient’s health information electronically. Your certified EHR already has Direct Secure Messaging, which allows you to get a C-CDA from the patient’s primary care physician, your local health information exchange, through a portal provided by your local hospital system, or from a data accumulator such as Carequality or Kno2. You likely know a C-CDA as an exam summary report or transition-of-care document. Your certified EHR creates both of them as does the EHR for every provider in your area. Regardless of the source, your certified EHR has the ability to extract individual pieces of data from the document and then transfer it into the exam fields in your EHR.

For a new patient to your office, a single click of the mouse will automatically populate a complete problem list, medication list, all the patient’s allergies and medical lab results. This gives you way more accurate information, completely documented in your exams, easier, with less time, and more accurate information than asking the patient as you likely did in the past.

For the physical exam, you no longer get billing credit for doing any additional testing beyond what is appropriate for the problem for which the patient presented. Since we have indicated in this exam that the patient does not have retinopathy and no other significant ocular findings, your physical exam will not take long.

This is the point where you make an important decision. If you want to continue to do an exam primarily aimed at simply detecting if diabetic retinopathy is present or not, you can end the exam at this point. You can tell the patient that they don’t have retinopathy and you will schedule another appointment in one year to see if retinopathy has developed. For this type of exam, you will be able to bill a low complexity, low-risk exam that does not require any care coordination.

If you decide to modify your exam to the type that is encouraged by the new E/M coding guidelines, as well as the updated American Optometric Associations Guidelines for Managing Diabetes, then you are going to need a clinical outcomes registry to help understand and manage the risk. From the data you brought in electronically, you can see that in addition to having diabetes, the patient has hypertension and lab results that show an elevated triglyceride. You will also see that todays’ HbA1c value is 8.4, but at the time of the patient’s last eye exam, HbA1c value was 7.2. Since todays’ HbA1c value is higher than one year ago, the risk of the patient developing diabetic retinopathy is higher.

The registry will show you what population of patients with diabetes that patient falls within, and give you access to data other offices are following to measure how well their efforts to improve the outcomes are working. For example, you might see that only 6.3 percent of patients in your office fall within this population. Some of the things you can do to reduce the risk you will be able to do in your practice. Other things you will need to coordinate with other members of the patient’s care team. These are the activities the new coding guidelines will pay you for and allow you to increase the level of billing for.

You can easily justify a higher level of billing under the new E/M coding guidelines once you combine the data that was brought in electronically, with the risk that the registry helped you understand.

Combining that information with your exam findings and the results of your discussion with the patient, you are now ready to write and implement a care plan that describes the risk and how you are coordinating the care with the rest of the team to reduce the risk.

James E. Grue, OD, is a health-care reform speaker and consultant. To contact him:



Ronald P. Snyder, OD, FAAO, is the president and CEO of HealthCare Registries, LLC. To contact him:

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