New Medicare office-visit coding guidelines are designed to be more intuitive and to promote good patient care over unnecessary documentation. But integrating them into practice management will take some in-house updates and perhaps some third-party advice to ensure practice readiness by Jan. 1, 2021, just a little more than a year away.
New evaluation and management (E/M) office visit code-selection criteria remove complex counting systems for history, exam and data that sometimes varied by payer. While these simpler and more flexible guidelines only apply to the office visit codes, they will be a big part of most practices.
Preparation will be key for a smooth transition and the AMA provides advice on how to do it. An AMA Ed Hub™ module, "Office Evaluation and Management (E/M) CPT Code Revisions," will help physicians and staff understand how these foundational changes will affect their work and reduce their documentation burden.
The AMA also has a detailed description of the changes and a table illustrating revisions related to medical decision-making documentation.
The revised guidelines were developed by a workgroup assembled by the AMA representing its Current Procedural Terminology (CPT®) Editorial Panel and the AMA/Specialty Society RVS Update Committee (RUC). The group was led by Barbara Levy, MD, a former RUC chair, and Peter Hollmann, MD, former chair of the CPT Editorial Panel.
Drs. Levy and Hollmann suggest looking at electronic health record (EHR) templates and considering how to get rid of the burden of wasted time by eliminating those that are not relevant.
If using total time on the date of an encounter as the basis for code selection, they suggest examining how time will be documented—including prep for patients, handling calls and non-face-to-face activities. They also suggest practices think about how to ensure that the record clearly comments on severity of illness and patient risk of treatment or non-treatment.
It may be necessary, however, to reach out to others for coding guidance and EHR technical adjustments. An AMA E/M checklist, which outlines the operational and infrastructure changes that are needed, also points out where to go when outside help is needed.
Before Jan. 1, 2021, the checklist advises the following.
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.
Be aware of medical 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 Litigation Center of the American Medical Association and State Medical Societies advocates on issues related to liability and is a resource on this topic.
Guard against fraud-and-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 navigate the audit and appeal process.
Check with your 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. AMA Steps Forward has a module to help you optimize your EHR and create a culture of shared accountability.
Drs. Hollmann and Levy have differing perspectives on the role of EHR vendors during the transition.
“Eventually, EHR vendors will adapt,” Dr. Hollmann said, adding that—in the meantime—he thinks “they probably won’t be a stumbling block or a big assist.”
Dr. Levy, however, thinks a heavier lift from the vendors will be required and said “it would be lovely” if they provided it.
“We would hope the updates to the EHR systems would be more clinically useful and centered around care of the patient as opposed to centered around billing,” she said.
Current systems force doctors into documenting things with little or no clinical value, while the new flexible requirements eliminate unnecessary box checking, so Dr. Levy believes vendors will need to create new templates and different documentation structures.
“I think the electronic medical record will have to catch up with the new coding structure,” she said.
