Early Changes in Billing and Notes after Evaluation and Management Guideline Change

Nate C. Apathy, Allison J. Hare, Sarah Fendrich, Dori A. Cross

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


BACKGROUND: The American Medical Association updated guidance in 2021 for frequently used billing codes for outpatient evaluation and management (E/M) visits. The intent was to account for provider time outside of face-to-face encounters and to reduce onerous documentation requirements.

OBJECTIVE: To analyze E/M visit use, documentation length, and time spent in the electronic health record (EHR) before and after the guideline change.

DESIGN: Observational, retrospective, pre-post study.

SETTING: U.S.-based ambulatory practices using the Epic Systems EHR.

PARTICIPANTS: 303 547 advanced practice providers and physicians across 389 organizations.

MEASUREMENTS: Data from September 2020 through April 2021 containing weekly provider-level E/M code and EHR use metadata were extracted from the Epic Signal database. We descriptively analyzed overall and specialty-specific changes in E/M visit use, note length, and time spent in the EHR before and after the new guidelines using provider-level paired t tests.

RESULTS: Following the new guidelines, level 3 visits decreased by 2.41 percentage points (95% CI, -2.48 to -2.34 percentage points) to 38.5% of all E/M visits, a 5.9% relative decrease from fall 2020. Level 4 visits increased by 0.89 percentage points (CI, 0.82 to 0.96 percentage points) to 40.9% of E/M visits, a 2.2% relative increase. Level 5 visits (the highest acuity level) increased by 1.85 percentage points (CI, 1.81 to 1.89 percentage points) to 10.1% of E/M visits, a 22.6% relative increase. These changes varied by specialty. We found no meaningful changes in measures of note length or time spent in the EHR.

LIMITATION: The Epic ambulatory client base may underrepresent smaller and independent practices.

CONCLUSION: Immediate changes in E/M coding contrast with null findings for changes in both note length and EHR time. Provider organizations are positioned to respond more rapidly to billing process changes than to changes in care delivery and associated EHR use behaviors. Fully realizing the intended benefits of this guideline change will require more time, facilitation, and scaling of best practices that more directly address EHR documentation practices and associated burden.


Original languageEnglish (US)
Pages (from-to)499-504
Number of pages6
JournalAnnals of internal medicine
Issue number4
StatePublished - Apr 1 2022

Bibliographical note

Funding Information:
Grant Support: By training grant T32-HS026116-04 from the Agency for Healthcare Research and Quality (Dr. Apathy) and by National Institutes of Health National Center for Advancing Translational Sciences grants KL2TR002492 and UL1TR002494 at the University of Minnesota (Dr. Cross).

Publisher Copyright:
© 2022 American College of Physicians. All rights reserved.


  • Documentation
  • Electronic Health Records
  • Humans
  • Medicine
  • Physicians
  • Retrospective Studies

PubMed: MeSH publication types

  • Research Support, U.S. Gov't, P.H.S.
  • Observational Study
  • Journal Article
  • Research Support, N.I.H., Extramural


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