Maximize your efficiency by overcoming key compliance issues.

Starting on Jan. 1, we will gain an impactful benefit from the Centers for Medicare and Medicaid Services’ (CMS’) Patients Over Paperwork initiative: “ … allowing doctors and non-physician practitioners to focus on care instead of paperwork.”¹ The burdensome documentation requirements of Evaluation and Management (E/M) coding has plagued ophthalmology since the loss of our full set of ophthalmology specialty eye code levels in the early 1990s.

While the current eye codes will remain unchanged, the onerous requirements of E/M guidelines will soon be gone. This will allow us to take an appropriate history and exam for each patient without wasting time and injecting frustration into patient visits by documenting irrelevant data for the sake of compliance. With that said, I will highlight the compliance issues and potential efficiencies gained from the new E/M documentation guidelines.

Documentation changes

Today, physician-patient face-to-face time or all three categories of history, exam, and medical decision-making (MDM) are required documentation for new patients, and two of the three categories are required for established patient visits with E/M coding. In 2021, history and exam will no longer be the basis for choosing the level of code. Providers will choose either MDM or time as the criteria for selecting the E/M code.

For MDM, there is a new and streamlined MDM table to consult for code choice.² MDM will be based on the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications and/or morbidity and mortality.³ Also, “addressed problem” has a new definition. Problems referred out, or commenting on problems others are managing that are not treated during the visit, will no longer be considered addressed problems for MDM.

If using time to determine the E/M code level, both physician-patient face-to-face and non-face-to-face time will be considered for the code level choice. Physician non-face-to-face activities (e.g., reviewing chart notes and past tests; counseling and educating the patient, family, or caregiver; and ordering tests, medications, and procedures) may be included in choosing time related to the visit.³ Updates also include changes to prolonged service codes.⁴ Practices need to be aware of these changes and review their methods of capturing time for work performed, which will likely result in new workflows.

In addition, a new complexity add-on code is planned for Medicare patients only.⁵

Upsides to changes

Since history and exam will no longer be considered in the E/M code choice, this allows practices to design their history-taking protocols to focus on the reason for the visit and expand upon it as necessary to care for the patient. Payer guidelines will still require the documentation of a chief complaint and relevant history to represent medical necessity for the visit.

For many years, administrators and compliance professionals have been responsible for training physicians and technicians on what is needed in patient charts for each visit to support compliance efforts. Now, the provider treating the patient will be able to control the medical care documentation training, as it should be. We can return to SOAP notes, which are documenting the relevant Subjective and Objective findings, Assessment, and Plan to support the care provided. Providers can return to setting their clinical workup protocols by disease entity or symptom presentation to facilitate their care of the patient, instead of onerous documentation requirements.

Moving forward

The American Medical Association advises providers to ensure they are still managing practice risk by: “Continuing to do only what is clinically required. To reiterate, the rules are simpler and more flexible. But adequate and accurate documentation is still necessary and can help adjudicate payment disputes and legal matters.”⁶ If the final rule is unchanged from the proposed version, there may be positive reimbursement reasons to use E/M codes.

Now is the time to begin training on the new guidelines to remain compliant and reap the benefits of the upcoming E/M code changes. OP

REFERENCES:

1. Centers for Medicare and Medicaid Services. Patient Over Paperwork. https://www.cms.gov/About-CMS/Story-Page/Patients-Over-Paperwork-fact-sheet.pdf . Accessed October 1, 2020.
2. American Medical Association. Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM). https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf . Accessed October 1, 2020.
3. Robeznieks A. How 2021 E/M guidelines could ease physicians’ documentation burdens. American Medical Associate. https://www.ama-assn.org/practice-management/cpt/how-2021-em-guidelines-could-ease-physicians-documentation-burdens . Accessed October 1, 2020.
4. American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf . Accessed October 1, 2020.
5. Centers for Medicare and Medicaid Services. Physician Fee Schedule Proposed Rule: Understanding 4 Key Topics. https://www.cms.gov/files/document/2020-08-13-pfs-presentation.pdf . Accessed October 1, 2020.
6. Robeznieks A. E/M prep: Avoid these pitfalls in move to new office-visit codes. American Medical Association. https://www.ama-assn.org/practice-management/cpt/em-prep-avoid-these-pitfalls-move-new-office-visit-codes . Accessed October 1, 2020.