After a long road of preparing for significant changes to Evaluation and Management (E/M) coding, revised policies on coding, documentation and payment of E/M services are now in effect. According to an American Medical Association (AMA) survey 100% of the major commercial payors said they would adopt new E/M guidelines, which means the changes that went into effect Jan. 1, 2021 have a significant impact on your program’s revenue cycle. It’s not too late to understand the evolution of E/M coding and documentation, and how to set your practice up for success in 2021 and beyond.
How Did We Get Here?
To understand how E/M changes came about, we must revisit the implementation of electronic medical records (EMRs) and travel back several years. Despite many benefits, EMRs forever changed the patient-provider interaction. The number of templates, checkboxes and sometimes burdensome details has resulted in lengthy, eight to 10-page notes lacking relevant details. The introduction of EMRs into the exam room also resulted in some patients feeling disconnected.
In 2018, the Centers for Medicare and Medicaid Services (CMS) released proposed coding changes which were considered flawed, resulting in a collaborative work group with the AMA. The work group developed alternative proposals that CMS included in the 2019 Medicare Physician Fee Schedule (MPFS) final rule. Ultimately, CMS adopted the AMA recommendations for office and outpatient E/M visit codes for calendar year 2021.
The overall goals of these changes are “putting patients over paperwork” aimed at:
- Reduce administrative burden of documentation and coding.
- Reduce the need for audits, by adding more detail to CPT codes to promote coding consistency.
- Reduce unnecessary documentation that is not needed for patient care.
- Ensure that payment for E/M is resource-based and that there is no direct goal for payment redistribution between specialties.
What Is the Impact?
On December 2, 2020, the Calendar Year (CY) 2021 MPFS was published in the Federal Registry. However, on December 27, 2020, the Consolidated Appropriations Act, 2021 modified the CY 2021 MPFS. The revised MPFS conversion factor for CY 2021 is $34.8931. Other provisions included:
- A 3.75% increase in MPFS payments for CY 2021
- Suspended the 2% payment adjustment (sequestration) through March 31, 2021
- Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
- Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024
The table below compares the wRVU and national reimbursement rates from CY 2020 to CY 2021.
The key 2021 E/M revisions and impacts include the following:
- Eliminating history and physical exam elements for code selection. No more “counting bullets, systems, areas, etc.” Providers document a medically appropriate history and/or exam based on the patient.
- Allowing providers to choose their level of service by documenting Medical Decision Making (MDM) or Total Time the day of the encounter.
- Modifications to the criteria for MDM to remove ambiguous terms, define previous concepts, and re-define data elements.
- Defining time to recognize the work involved on the date of service for non-face-to-face and face-to face total time by physicians and qualified health care professionals.
Correct CV Documentation Is Key
Document the elements of MDM:
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- Include the nature and number of problems “addressed,” the data used to make decisions, and the patient risk based on their conditions, management and/or treatment.
- The definition of problems “addressed” is specific: “a notation in the medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being 'addressed' or managed.” So just listing the condition in the problem list and/or who is treating it would not meet the requirements.
- Example: “diabetes, stable, on insulin, AIC monitored by Dr. Smith.”
Data element of MDM:
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- Each unique test, order or external note reviewed counts as a contribution to the data segment.
- Example: Documenting orders for a CBC, lipid panel, EKG and echo would count as four “unique” tests. Documenting labs and diagnostic ordered would count as two. One area that has been defined is independent interpretation of test results.
- If you or someone in your practice, under the same Tax ID, is billing for the interpretation of the test you cannot count this as an independent interpretation in any visits toward MDM. You get credit for the initial order only. We are hoping for further clarification from CMS and the AMA as we know in CV services there are many independent reviews of data and comparisons of studies.
Total visit time:
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- This has been revised to include both face-to-face and non-face-to-face time personally spent by the physician and/or other qualified healthcare professional(s) (QHP) on the day of the encounter. This does not include the time spent on activities normally performed by clinical staff.
- Documentation of physician/QHP time should be exact. Avoid vague wording such as “greater than X minutes.” Start and end times are also acceptable.
- The AMA has provided a list of activities that may be counted toward a physician’s total time. The guidelines offer examples of preparing for the visit; getting or reviewing a history that was separately obtained; performing the exam; counseling and providing education to the patient, family or caregiver; ordering medicines, tests or procedures; communicating with other healthcare professionals; documenting information in the medical record; interpreting results and sharing that information with the patient, family or caregiver; and care coordination.
- Reviewing templates to capture the time pre, intra and post visit along with the details of what activities the time represents are a good way to capture total time.
Why Does it Matter?
The new coding and documentation changes are the first major overhaul to E/M guidelines in nearly 30 years. We are hearing commercial payers are on board with these changes. It is important to remember there is no change to the 1995 and 1997 guidelines for all other E/M visit categories (inpatient admit, observation, discharge, ER, etc.)
MedAxiom ended 2020 offering several education sessions regarding the E/M code changes and the impact on cardiology. We have continued to receive positive feedback from providers on the new guidelines. The AMA simplifying the code selection criteria and making them more clinically relevant and intuitive has eased the adoption of the changes.
Looking ahead, E/M coding will remain a significant part of CV programs. Ongoing provider education, chart reviews and consistent feedback are key to success. Updates to EMR systems that have current E/M calculators will need to be revised and careful attention should be paid to monitoring the changes.
Although all the implications are not definite, it is hoped the changes will improve efficiency while reducing administrative burdens and ultimately improve patient care.
Visit MedAxiom’s Revenue Cycle Solutions Hub for education and resources to help you navigate E/M changes.
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