Original Research
22 February 2022

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

Publication: Annals of Internal Medicine
Volume 175, Number 4
Visual Abstract. Early Changes in Billing and Notes After 2021 E/M Guideline Change.
Regulatory changes to billing codes for outpatient evaluation and management (E/M) visits were intended to reduce documentation requirements and account for provider time spent coordinating care for patients. This study analyzes national data on changes in E/M visits, note length, and time spent in electronic health records before and after regulatory changes in 2021.



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.


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


Observational, retrospective, pre–post study.


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


303 547 advanced practice providers and physicians across 389 organizations.


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.


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.


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


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.

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Information & Authors


Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 175Number 4April 2022
Pages: 499 - 504


Published online: 22 February 2022
Published in issue: April 2022




Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, and Regenstrief Institute, Indianapolis, Indiana (N.C.A.)
Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.J.H., S.F.)
Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.J.H., S.F.)
Dori A. Cross, PhD
Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota (D.A.C.).
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health National Center for Advancing Translational Sciences.
Acknowledgment: The authors thank Debra Laumer, Santana Briones, and Sarah LaMar from the PennMedicine EHR Transformation team for their assistance in acquiring pilot data for this study. The authors thank Drs. Bill Hanson, John McGreevey, J.T. Howell, and Rachel Werner for their support for the project. Finally, the authors thank Chris Gates from Epic Systems for his assistance in extracting the data for this study.
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).
Reproducible Research Statement: Study protocol: Not available. Statistical code: Available from Dr. Apathy (e-mail, [email protected]). Data set: Data available pending release approval from Epic Systems; contact Dr. Apathy if interested.
Corresponding Author: Nate C. Apathy, PhD, Perelman School of Medicine, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104; e-mail, [email protected].
Author Contributions: Conception and design: N.C. Apathy, S. Fendrich, D.A. Cross.
Analysis and interpretation of the data: N.C. Apathy, A.J. Hare, S. Fendrich, D.A. Cross.
Drafting of the article: N.C. Apathy, A.J. Hare, D.A. Cross.
Critical revision of the article for important intellectual content: N.C. Apathy, A.J. Hare, D.A. Cross.
Final approval of the article: N.C. Apathy, A.J. Hare, S. Fendrich, D.A. Cross.
Statistical expertise: N.C. Apathy.
Administrative, technical, or logistic support: N.C. Apathy, A.J. Hare.
Collection and assembly of data: N.C. Apathy.
This article was published at Annals.org on 22 February 2022.

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Nate C. Apathy, Allison J. Hare, Sarah Fendrich, et al. Early Changes in Billing and Notes After Evaluation and Management Guideline Change. Ann Intern Med.2022;175:499-504. [Epub 22 February 2022]. doi:10.7326/M21-4402

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