2021 E/M Coding in ExamWRITER

Under the E/M coding and guideline changes that take effect January 1, 2021, Providers may choose to base the E/M level for each patient encounter on medical decision making or total time.

ExamWRITER includes all of the CPT codes needed to bill under both coding methods. To ensure your systems have the latest CPT codes, update your OfficeMate/ExamWRITER software to version 15.3. 4033. However, the Quick Code window has not yet been updated to accurately determine the level of E/M documentation under the new guidelines. Look for an ExamWRITER update that includes a redesigned and updated Quick Code window in early 2021.

Billing by Medical Decision Making

There are four levels of MDM: straightforward, low, moderate, and high. To learn more about the elements that contribute to these levels and their associated CPT codes, refer to Understanding E/M Coding Levels.

Print the PDF and refer to it to determine the E/M code level of your exam documentation until the Quick Code window has been updated to address the new guidelines.

Billing by Time

If you choose to bill the visit based on time, follow the instructions below to document the total time within the exam:

1. Click the Surgery - Plan - Mgmt tab on the ExamWRITER chart window.
2. Click the Patient Management
3. The Patient Management window opens.
4. Select the Timeline check box and click Process.
5. Select the check box that represents the total time spent on the encounter and click Process.

Refer to the table below to determine the appropriate code to select in the Coding window.

New Patients		Established Patients
Time (minutes)	Code	Time (minutes)	Code
—	—	No time set	99211 (minimal problem)
15–29	99202	10–19	99212
30–44	99203	20–29	99213
45–59	99204	30–39	99214
60–74	99205	40–54	99215
>75	99417 ×1 for each additional 15 minutes	>55	99417 ×1 for each additional 15 minutes

Finding Additional Information

This section also includes the following topics:

• Understanding the 2021 Evaluation and Management (E/M) Changes
• Billing Based on MDM or Time
• Understanding E/M Coding Levels
• 2021 E/M Coding in Eyefinity EHR
• Understanding the Default E/M Complexity in Eyefinity EHR