Since the 2021 AMA E/M code revisions, documentation requirements for office visits have been simplified. But despite the changes, studies show that over 40% of physicians still under-code their encounters — leaving thousands of dollars per year in unreimbursed revenue.
The 2021 E/M Overhaul: What Changed
Prior to 2021, E/M level selection was based on a specific number of exam elements, history items, and medical decision-making (MDM) components — a rigid documentation checklist that incentivized bullet-point medicine rather than genuine clinical reasoning. The 2021 revision changed the basis for level selection to either total time or MDM alone.
How AI Billing Suggestions Work
NexiScribe's billing AI analyzes the generated SOAP note and identifies the complexity of medical decision-making documented in the note. It then suggests the appropriate E/M level with a confidence score and a brief rationale — so the physician can confirm or adjust before signing.
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