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Changes in Practice Management: Looking Ahead to 2021 and Beyond

Providers can expect some notable changes to the key coding guidelines for evaluation and management (E/M), which the Centers for Medicare & Medicaid Services will implement on January 1, 2021. These changes primarily concern aspects of patient history and exam, medical decision-making, and time, according to Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC, Partner/VP and Chief Compliance Officer at Doctors Management. Importantly, the changes to the 2021 E/M codes are applicable only to office or other outpatient service codes; hospital and other E/M codes will not be affected by these changes.

During the the ACR Convergence 2020 conference, Mr Weiss provided a detailed discussion on the changes providers can expect next year.

E/M Changes for 2021

“While I do believe providers will see some benefits with the administrative simplification or ‘scale-back’ to some of the obligations required from a documentation standpoint, I also believe that these 2021 guidelines are a trap in many regards, because the E/M service changes that are taking place are only limited to office or other outpatient E/M services. Navigating away from the current structure and requirements of E/M services is not a good idea,” he said.

History and Exam

First, history and exam will no longer be scored, meaning the elements will not be counted toward the overall level of service. However, those elements must still be present in the note to substantiate medical necessity, defined as “healthcare services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are in accordance with generally accepted standards of medical practice….”

Coding and documentation guidelines will generally always require modifications, and Mr Weiss predicts a significant number of revisions to these published guidelines.

“I believe payers have not taken into account the financial repercussions resulting from what will ultimately be an increase in E/M services, now that the history and exam are no longer counted as part of the overall documentation,” he said.

The “Gotcha,” he added, is the fact that these services are not only based on medical decision-making or time; they are based on medical decision-making in conjunction with medical necessity, and time in conjunction with medical necessity. “At the end of the day, medical necessity is the overarching criteria,” he said.

In response to this and because they believe that the level of service will come down to medical decision-making or time, some providers may try to manipulate their manner of documentation to cut out portions of the history or exam.

“But these providers might be putting themselves in a potentially adverse situation, because the medical necessity is critical,” Mr Weiss noted. “Histories, although they are not going to be counted, are still going to be reviewed by the payers. They still paint a clear picture for a reviewer as to why the patient is coming in.” He added that the chief complaint must always be well documented, preferably in the patient’s own words.

Medical Decision-Making

When it comes to medical decision- making, the first revision of note is that only diagnoses documented as active treatment during the present encounter will be considered for scoring purposes. “So those of you who have not gone in and cleaned up your active problem list, and you still have 20 or 30 active problems, they’re not going to count those,” stated Mr Weiss. “They’re not willing to engage in reviewing those if they are not actively treated during that encounter.”

Regarding the data complexity aspect of medical decision-making, there will be new requirements for specific combinations of different work elements to support a specific level of data and complexity.

“I think the most complex change took place in the table of risk in the medical decision-making chart,” he said. “The entire table of risk has been consolidated into one column on a new Medical Decision Making grid and uses only the last column of treatment for the patient’s options.”

Time Spent

Mr Weiss emphasized the importance of understanding that the patient visit will no longer have to be dominated by counseling and/or coordination of care. Time spent now refers to the rendering provider’s total time spent, including non–face-to-face time spent specific to the encounter and patient. In other words, a physician will bill for a patient encounter based on overall time spent on the day of the encounter, as opposed to being required to note that a majority of the encounter was spent engaging in counseling and/or coordination of care.

“Remember that medical necessity is still going to have to be reflected within the documentation of each encounter,” Mr Weiss stated.

Amount and Complexity of Data to Be Analyzed

For providers, not much has changed when it comes to the complexity of data to be reviewed and analyzed, although the scoring process has changed significantly. “There are now 3 categories within this section that have to be analyzed,” Mr Weiss said.

Category 1 is basic office visit “work,” including a review of prior external notes, a review of testing results, ordering of tests, and assessments requiring an independent historian. Category 2 looks at additional work including the independent interpretation of testing. Category 3 relates to any further workup required for a patient, including any discussion of management or test interpretation with any other provider, including an MD or DO, or any non-physician practitioner including a PA or NP.

Mr Weiss referred to the American Medical Association definition of risk for the purposes of understanding the risk of complications and/or morbidity or mortality of patient management, particularly the section that states: “Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.”

He stressed the importance of the words, “in the same specialty,” meaning a family practitioner should not be weighing in on whether an orthopedic surgeon’s treatment is medically necessary.

If defending medical necessity becomes necessary, Mr Weiss said that he considers several factors. First, does medical necessity exist (or likely exist), but it is lacking documentation in the medical record?

“If that’s the case, we may be able to add a late entry and/or an addendum if it’s reasonable and it makes sense,” he said. “Remember, physicians have a responsibility to provide sufficient documentation that paints a clear picture of each and every encounter.”

Second, determine whether the procedures in question are truly clinically necessary. Third, be certain that all relevant medical records have been retrieved and reviewed (eg, office notes, hospital notes, nursing homes, rehabilitation, etc). Include any and all correspondence that may increase overall clarity in the picture of the patient encounter. Ask whether local or national coverage determinations exist to provide documentation requirements. Finally, if the allegations assert that documentation is inaccurate, ask yourself whether you have generated clinical rebuttals to further clarify the need for services and state the physician’s opinion clearly.

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