New clinical coding guidelines account for patients’ social risk: We should do more to ensure they advance health care quality and equity

On January 1, 2021, new evaluation and management (E&M) coding guidelines for clinical office visits go into effect across the US. These guidelines, which reflect the most significant change in E&M coding undertaken since 1997, could rapidly affect up to 40 percent of all Medicare physician fee schedule charges and contribute to cost increases for people who pay all or part of their outpatient medical bills. One change in the new guidelines is that the billed “level of service” will be based largely on total time spent or the complexity of the clinician’s medical decision making during the office visit. The new emphasis on medical decision making leads to a far more subtle but potentially more important change in the updated guidelines: For the very first time, assessment of the complexity of medical decision making can take into account a patient’s socioeconomic risk factors.