2021 will see new, sweeping guideline changes for providers in coding and documentation for office and other outpatient visits. These changes will affect guidelines not revised since 1997. Physicians and other clinicians will base their evaluation and management (E/M) levels of service on the documentation of time or medical decision-making only, with new definitions of both, so they don’t have to factor in the history and exam, although they still must be medically appropriate. With the clock ticking, providers and their staffs need to prepare now.


2021 Guideline Training For:

  • Executive/Compliance/Legal Team
  • Coding/Billing Team
  • Coding Auditor Team
  • Physician/NPP Team

2021 E/M Documentation Gap Analysis Process:

  • Review a sample of records per provider or specialty group
  • Determine potential coding and reimbursement change based on sample from 2020 to 2021
  • Determine documentation improvement recommendations for providers
  • Review EHR capabilities and limitations and recommend system utilization methods and templates to align with new guidelines

EHR Vendor Consulting Support

  • Expert guidance on system changes to support documentation and coding compliance



PYA offers compliance advisory services that include hospital inpatient and outpatient coding and compliance services. Our team of experienced professionals understands the documentation and coding challenges organizations face to achieve healthcare compliance. Our expertise is reflected by the following certifications and credentials:

  • Certified Professional Coder CPC (CPC®)
  • Certified Professional Medical Auditor (CPMA®)
  • Certified Evaluation and Management Coder (CEMC™)
  • Certified Orthopaedic Surgery Coder (COSC™)
  • Registered Health Information Administrator (RHIA)
  • Registered Nurse (RN)
  • Certified Coding Specialist (CCS)
  • Certified Outpatient Coder (COC)
  • AHIMA-Approved ICD-10-CM/PCS Trainer
  • Certified Professional in Healthcare Quality (CPHQ)