CMS 2021 Evaluation & Management Guidance

Effective January 1st, 2021, the Centers for Medicare & Medicaid Services (CMS) Evaluation and Management (E&M) coding and documentation requirements have been changed. While some of the items remain the same, some of the items to keep in mind include:

  • Coding for new patients is limited to 4 levels. Established patients remains with 5 levels.
  • Time requirements needed to select a level has been revised.
  • Recording and collection of history and exam varies based on medical need.
  • Level of the visit may be selected based on time or medical decision.

The general principles of the Evaluation and Management visits are based on documentation and consistency of the documents with patient coverage and the services provided.


  • Clear and concise. Simply record the patient’s conditions, plan of action, care provided, pertinent facts, findings, and observations about the patient’s health history.
  • In other words, this means that any information in the medical record must be legible to individuals other than the author.

Consistency with patient coverage as it regards to:

  • The site of service
  • The medical necessity of services
  • The services provided are timely and accurately documented.

Note: Remember that in order to be reimbursed for E&M services, the provider must be licensed in the state and the services performed must be within the scope of the license and covered by the respective Payor.

For more information visit the EPI Conference website and search for CMS E&M Guidelines.