E&M coding Changes for Otolaryngology

An Otolaryngologist is a physician who treats diseases of the head and neck, both medically and surgically. It also includes diseases of the external, middle, and inner ear, the nose, oral cavity, neck, and facial structures. E&M coding changes for otolaryngology also had a major impact on its practices. Healthcare professionals or otolaryngologists would have been aware of the coordinating CPT code changes, which will allow you to base E/M levels on either a provider’s time or medical decision making (MDM).

The Centers for Medicare and Medicaid had explained clearly about the redefined time and MDM to make documentation requirements. But it requires some understanding. In this article let’s learn about the E&M coding changes and how should it be used in the practices while billing and coding for the procedures.

History and Exam do not belong to the past in E&M coding:

  • History and exam are no longer the key components for code selection. Moreover, CMS particularly is adding a requirement and necessity to include history and exam in the documentation.
  • The revised code descriptors will include the phrase, “which requires a medically appropriate history and/or exam” in order to reflect the change.
  • Healthcare professionals must determine the change of what is necessary medically on a case-by-case basis and document accordingly.
  • Healthcare professionals would require only the document of what has changed from the last encounter which is based on 2019 and 2020 CMS final rules.
  • However, “We need to be clear on what’s old information and what’s new information for the date of service,” Kipreos says.

When does time become the determining factor?

  • In the Medicare Physician Fee Schedule (MPFS) final rule, CMS actually proposes to redefine the time from face-to-face time to total time spent on the day of the encounter. They include:
  1. Preparing to see the patient (e.g., review of tests)
  2. Obtaining and/or reviewing separately obtained history
  3. Performing a medically appropriate exam and/or evaluation
  4. Counseling and educating the patient/family/caregiver
  5. Documenting clinical information in the medical record
  6. Independently interpreting results and communication results to the patient/family/caregiver
  7. Care coordination
  • There’s never an indication of final rule that time must be itemized. It’s also expected that CMS will clarify what’s needed in the documentation in the 2021 MPFS proposed rule.
  • The actual challenge lies in getting providers to track their time with each patient as well as time spent determining and executing care. “Introduce this thought process to your provider now,” Kipreos advises.
  • Kipreos also advises healthcare providers to begin tracking how much face-to-face and non-face-to-face time they spend on each patient, on an average.
  • This moreover helps them to determine if it’s generally more appropriate for them to code based on time and MDM.

When MDM becomes the determining Factor:

  • E&M coding is based on MDM. It will need to assess three MDM elements, which also will be revised as follows:
  1. “Risk of complications and/or morbidity or mortality” will be changed to “Risk of complications and/or morbidity or mortality of patient management.”
  2. “Number of diagnoses or management options” will become “Number and complexity of problems addressed.”
  3. “Amount and/or complexity of data to be reviewed” will be changed to “Amount and/or complexity of data to be reviewed and analyzed.”
  • A diagnosis actually does not only depend on the complexity of risk. While considering the number and the complexity of problems addressed, the coders are supposed to examine how extensive the evaluation was and if multiple lower-severity problems collectively create a higher risk due to interaction.
  • A part of these guidelines should be able to count for all that work that goes into the final diagnosis, into the management of the patient.
  • Underlying diseases are not considered for E&M coding levels unless the healthcare professional takes it into consideration in the management of the patient.
  • In order to count the level of service, the documentation must indicate these conditions that are being addressed. In doing so, it will affect what is being ordered, or they will complicate the management.
  • CMS indicates in the 2020 MPFS final rule, “A problem is addressed or managed when it is evaluated or treated at the encounter. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service.”
  • They use two different words. It’s essential to think about that. It can be addressed even if it’s not managed by the healthcare professional.
  • It’s also better to think if the healthcare professional gave the information in the documentation to clarify its difficulty.
  • Drug therapy, another element of risk, is further defined to help us understand documentation requirements. When a healthcare professional initiates the management with a drug, they should probably document any adverse effects to the therapy that require monitoring.
  • Healthcare professionals should specify the justification for monitoring the documentation. It must be clearly documented along with the reason as to why the monitoring is needed.

Clinical Documentation Improvement

Providers will need to improve their documentation to support the new E/M coding guidelines. Educate your providers to:

  1. Communicate the complexity of the patient’s condition
  2. Provide a clear assessment and plan
  3. Indicate the number of tests being ordered, with rationales
  4. Include documentation for interpretations, when performed
  5. Continue to document clinically appropriate histories and exams

E&M Coding example:

The patient is here with severe nasal congestion, drainage, and a sore throat. Has had a cough. Thought he had the flu about 2 weeks ago. He stayed in bed for 5 days. Had a high fever and that is when the cough started. Fever went down. Thought he was feeling better, he started coughing and now it keeps him awake. Has a history of hypertension and has to watch his heart rate. Has had an MI and stent placement. He is a regular patient of Dr. X. He did have the flu and pneumonia vaccines. He is a nonsmoker. Pain is 0 on scale, with 0 being no pain and 10 being the worst. No vomiting or diarrhea. No history of asthma. ROS remaining are negative.


  • Penicillin
  • Sulfa
  • Cholesterol tabs
  • Had to take Cipro for a long period of time for a urinary tract condition. He developed an adverse reaction to it. Has had Levaquin since then and has done okay. His mother is allergic to Cipro.

Chest X-ray: The heart and mediastinum are normal. No lymphadenopathy is seen. The lung fields are clear.


  • Acute sinusitis 2. Postnasal drip 3. Acute bronchitis


  • I have prescribed him an inhaler before. Gave him an Albuterol inhaler 12 puffs q 4-6 hours, prn #1, no refills.
  • Should be able to use Guaifenesin 600 refills.
  • Levaquin 500 mg 1 q day times 10.
  • Rocephin 1 gm IM now.
  • Increase fluids.
  • Diet as tolerated.
  • Schedule a follow-up appointment with Dr. X, especially if symptoms worsen or he is not doing well.
  • He was receptive to these suggestions.
  • No communication barriers.
  • Questions were answered to the best of his ability and reported to satisfaction.


E&M coding might seem little confusing for healthcare professionals, as it is not easy to manage them with regular patient responsibility. Outsourcing coding services to healthcare billing companies can save the business from loss of revenue.


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