As we continue preparing for the E/M code changes in 2021 it's easy to get caught up in the reduction of clicks and adding things to the note so you get enough bullet points to meet a specific level.  However, don't overlook the fact that this is the time to make sure your documentation is up to par.

More than ever - documentation of medical necessity for an appointment will be crucial to surviving an audit down the road.  While the new rules eliminate specifics that were previously recorded, medical necessity is still a requirement.  

I know a lot of providers cringe when you talk about documentation, but I really believe the new rules will help tremendously if you (or your providers) can create a habit of simply documenting what you are thinking to make a decision.  That's it.  If you considered their hypertension when you selected a specific medication, document it.  Lay out a narrative of what happened.  Instead of clicking meaningless boxes to get your level, you simply need to document the nitty gritty.  Reviewed labs and see something that needs further testing or treatment?  Write it down so medical necessity for the next step is clearly outlined in your note.

In 2021 the challenge will be to go from clicking and copy/paste habits to ending your patient visit with a note as unique as the care you have provided to your patient in that visit.  Before settling into a potentially bad habit with documentation under the new guidelines, think about have a documentation audit.  The results will help customize training for areas of improvement.  Use the contact us page if you'd like more information!

It seems the only constant in the world of medical billing is change.  2020 definitely didn't disappoint.  While the chaos of Covid forced unexpected changes this year, 2021 has a big change that you have time to prepare for! This change is exciting as it addresses the Patients Over Paperwork initiative from CMS and the AMA has helped in hopes to eliminate "Note Bloat".  The new year will roll out changes to E/M visits - make sure that all parties are prepared for this welcomed and long overdue change to medical billing!  
 
Evaluation and management services have been long overdue for an overhaul.  The 1995/1997 guidelines were in place well before electronic medical records, and with the growth of EMR's the process to document for a specific level required a lot of tedious, unnecessary documentation.  Take a look at some of the proposed updates for E/M CPT Coding and documentation requirements!

• History & Examination While the elements of history and examination that are pertinent to a specific visit shall be recorded, they will no longer be used to 'score' the level billed.

 

• Code Selection will be based on MDM or Time!  Medical Decision Making will still utilize the CMS Table of Risk time based code selection will be simplified.

The wording and explanations for MDM are being updated to provide better explanations and concise language.  For instance, definitions will now be included to clearly identify subjective wording like Self-limited and stable, chronic illness.  The clinical examples will be removed, instead using terms that are described in a clearer definition.  We will see this same type of clarification the MDM table, for example - the 2021 guidelines will specify that the amount and/or complexity of data to be reviewed must also include analysis.

For those using time for code selection, the guidelines will give specific minute ranges rather than the generic estimate that we currently see attached to E/M codes.  Another major advantage to the codes selected based on time - it now includes non-face-to-face services!  There will also be additional add on codes in 15-minute increments if the time has been exceeded for the 99205 or 99215.

While changes are daunting, I think you will find this change to be rewarding from a documentation standpoint.  If you would like help preparing your team for these changes, RCM Insight can help.  We offer training and documentation auditing.  Contact us today for more information on how we can help!