The coding and documentation requirements for evaluation and management (E/M) of office and outpatient services are set for a big change. Starting Jan. 1, 2021, physicians can decide whether to code E/M visits by medical decision-making or by total time, including nonpatient-facing activities, such as looking at past medical records, talking to other physicians and even talking to the patient’s family. The final rule from the Centers for Medicare and Medicaid Services also allows for shared visits, in which a physician and another qualified healthcare professional, such as a nurse practitioner or certified nurse specialist, to jointly provide services related to the visit.
While major, the changes are a welcome relief to outpatient providers and physician practices that have struggled with tedious, onerous documentation requirements that had been in place since the 1990s—before electronic medical records were the norm.
“These requirements had been out of date and antiquated for a long time,” says Julie Seaman, director of coding and CDI for eCatalyst. “Much of the data that physicians were required to enter were either somewhere else in the medical record or not important to that visit. The new rules have gotten rid of the history and exam requirement for determining level of visit. This will help reduce the burden on physicians and require them to document—and do—only what they deem is important and pertinent.”
It’s a win for providers but complying with these new coding requirements will require both operational and workflow changes.
“It’s a huge change,” she says. “This is going to require changes to the EMR, and it’s going to change how practices utilize their staff, now that histories don’t have to be documented by the physician and shared visits are now allowed.”
At eCatalyst, Seaman has been busy helping physician practices and outpatient clinics get up to speed on these fast-approaching changes. Here are some of her tips for being prepared:
Create new EMR templates for types of visits
Because physicians only have to document the pertinent pieces of information related to a patient’s visit, practices will want to create individual templates for different types of visits. Could this be a lot of templates? Perhaps, but Seaman says it will be time well spent because it will ensure that each template has fields for all of the relevant information.
Don’t forget about HCC quality measures
Whether in the EMR templates or elsewhere in the new workflow, Seaman says it’s important to make sure you’re still capturing quality measures for hierarchical condition category (HCC) coding. For example, for a patient with diabetes, it’s important that you’re still capturing things like A1C level and annual podiatrist and ophthalmologist visits somewhere. This could be as part of the face-to-face time with the physician, or now it could be via a self-survey in the patient portal or at the beginning of the visit with a non-physician clinician.
Rethink staff workflows and roles
Under the new rules, a history still has to be taken—just not by the physician. Whose role will this be? How will it impact the patient visit? Additionally, for practices and outpatient clinics that already have non-physician practitioners on staff, it’s smart to take a look at their roles and how they can be better utilized under the new rules, which allow their time to be captured as part of the E/M service.
Be flexible to maximize the level of service
Physicians can choose to bill by time or medical decision-making on any given visit—and they don’t have to decide up front. In general, she says, a new patient visit would likely be billed by time. “They spend a lot of time researching, looking at records, talking to physicians, talking to the family and talking to the patient,” she says. If it’s a checkup with an established patient with multiple chronic conditions, however, that might be better billed as medical decision-making.
Until it becomes clear which way helps practices arrive at the right the level of service, she encourages flexibility and the possibility that it could go either way. That means thoroughly documenting time spent and all relevant information. “Capture everything so you can bill for the correct level of care,” she says.