The AMA is dedicated to reducing documentation burdens that interfere with patient care. We worked together with CMS to overhaul Evaluation and Management (E/M) office visit codes for the first time in more than 25 years.
To learn more about these significant code set revisions, visit our CPT E/M webpage. Additionally, the AMA has created an interactive educational module and a detailed description of the code and guideline changes (PDF), along with a table of the elements for each level of medical decision making (MDM) (PDF). The MDM grid illustrates office revisions to educate physician practices.
Physician practices are encouraged to start planning now for the operational, infrastructural and administrative workflow adjustments that will result from this overhaul. The following checklist will help you prepare and keep you out in front of these changes.
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Identify a project lead
The transition to the revised E/M office visit coding guidelines will require staff education, review of internal policies and procedures and financial tracking. Specify a project lead who is charged with leading the transition. For pointers on how to lead change within your practice, see the AMA STEPS Forward™ module on organizational leadership and change management.
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Schedule team preparation time
The best way to educate your practice about these upcoming changes will be to walk through them with the practice’s physicians, other clinical staff and administrative personnel. Practices should schedule time for in-person gatherings to review the changes and to surface and address questions. AMA STEPS Forward™ outlines how to run an efficient and productive team meeting. An AMA Moving Medicine podcast addresses this topic as well.
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Update practice protocols
Practice procedures and protocols must be updated to be consistent with the new guidelines. AMA recommends leveraging your practice’s established coding resources and expertise early in the update process.
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Consider coding support
There are significant changes to the codes and documentation for office visits. See the AMA’s resources on ancillary staff E/M documentation and the AMA STEPS Forward™ module on team documentation. Use all appropriate coding resources to properly prepare for these revisions. Visit the AMA’s E/M office visit educational website to learn more about the changes and take the module to see how the revisions will help reduce administrative burden.
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Be aware of medical malpractice liability
Although the requirements around E/M documentation may have lessened or become more flexible, physicians should still carefully document the work that is being done and how to protect themselves from medical malpractice suits. The AMA Litigation Center actively advocates for physicians on issues related to liability and is a resource on this topic
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Guard against fraud & abuse law infractions
The False Claims Act and other federal and state fraud and abuse laws remain in effect. Although the new E/M office visit coding guidelines allow greater flexibility, practices should continue to document appropriately and guard against inadvertent overbilling. If your practice does bill appropriately under the new E/M documentation guidelines but still receives an overpayment demand, the AMA has resources to help you navigate the audit and appeal process.
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Update your compliance plan
Many practices have a compliance plan to help avoid ethical and legal mistakes. The U.S. Department of Health & Human Services has a roadmap to help physician practices develop and implement a compliance plan. As your practice undergoes the transition to the new E/M guidance, ensure that your updated protocols and procedures remain consistent with your current compliance plan.
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Check with your electronic health record (EHR) vendor
Practices should communicate with their EHR vendor to confirm their schedule for implementing these E/M office visit code changes. The AMA is working closely with EHR vendors from across the country to make it as straightforward as possible to implement the changes in their systems.
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Assess financial impact
Guard against an unanticipated financial impact by understanding the rules in advance and performing a prospective financial analysis. This may help you anticipate a dip or increase in revenue and aid in other practice business decisions. The AMA has resources on when to engage an external advisor to help navigate business issues.
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Understand additional employer or payor or medical liability coverage requirements
Employers or payors may still require documentation of additional information above and beyond the new E/M office visit coding guidelines. Physicians should carefully evaluate the flexibilities allowed under the new guidelines and ensure that their documentation will satisfy any other obligations and requirements that they may be expected to fulfill. The AMA is engaging a number of entities to ensure that the burden reduction potential of the new E/M office visit changes is fully realized.
