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!