White Paper

3 Pages
  • 3 Pages

5 Keys to E/M Coding and Documentation Changes in 2021


Learn about new coding guidelines.

For more than two decades, doctors have been coding for Evaluation and Management (E/M) services based on three essential elements of history, exam, and medical decision making (MDM). These guidelines, particularly in regard to MDM, have been vague and understood in a variety of ways. This white paper reviews that medical necessity is the overall precedent for deciding the appropriate level of service and discusses what that means when it comes to documentation.



Carol Hoppe, CPC, CCS-P, CPC-I

Carol Hoppe, CPC, CCS-P, CPC-I

MedLucid Solutions, LLC

  • President and CEO of MedLucid Solutions, LLC, providing clear solutions for medical practices
  • Assists clients with all aspects of coding, billing, A/R and practice management for professional health care services, including chart reviews, education, practice assessments, practitioner shadowing, and interim management support
  • Conducts regular seminars and workshops on numerous topics, including E/M documentation guidelines, annual coding updates, and specialty specific coding sessions for clinicians and staff
  • Certified Professional Coder (CPC) and a Certified Professional Coding Instructor (CPC-I), American Academy of Professional Coders (AAPC); Certified Coding Specialist Physician Based (CCS-P), and American Health Information Management Association (AHIMA)
  • Taught medical billing and coding as an adjunct instructor at Sanford Brown College, Indianapolis; online adjunct instructor at Ultimate Medical Academy
  • Published author on articles related to billing, coding and A/R management
  • Current member of the WPS Medicare Part B J8 Provider Outreach and Education Advisory Group (POE AG)
  • Billing, coding and practice management representative for the Indiana State Medical Association
  • B.S.M. degree, summa cum laude, Indiana Wesleyan University
  • Can be contacted at 317-537-7553, [email protected], www.medlucidsolutions.com or on LinkedIn® and Facebook®

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