Evaluation and management changes are coming to outpatient care sites

Jennifer SwindleCoding

The Centers for Medicare & Medicaid Services’ 3-year-old Patients over Paperwork initiative, designed to free doctors and non-physician practitioners to focus more on patient care, has led to the first major revision of evaluation and management (E&M) office visit codes in more than a quarter century. The changes are limited to medical office/outpatient services, but they are significant and will require effort to prepare.

In 2018, the American Medical Association assembled a joint work group representing its Current Procedural Terminology (CPT®) Editorial Panel and the AMA/Specialty Society RVS Update Committee. The group worked with CMS and convened a coalition of 170 state and specialty medical societies to simplify the requirements and make them clinically relevant. One of the main goals is to reduce the administrative burden by getting rid of redundant and/or unnecessary documentation in the medical record that does not have a meaningful impact on actual patient care.

Obviously, much has changed since the 1995 and 1997 versions of E&M. Those could not have anticipated the impact that electronic health records would have on provider documentation. Healthcare today is more focused on patient needs and utilizes a team model not seen as much that many years ago.

Medical necessity still critical
One thing that has not changed and is not impacted by the changing guidelines is that medical necessity should be the overarching criterion for determining the level of service.

The big changes to E&M are:

  • The level of service will be determined either by medical decision-making or by time
  • Elimination of CPT code 99201 for new patient visits. There will be no variation from new to established patient for documentation content, medical necessity or medical decision-making.
  • History and examination documentation will not be factored into determining the level of service

Significant changes were made in how to determine the medical decision-making component to correlate it with medical necessity. Extensive edits were made to the elements for code selection, including removing ambiguous terms such as “mild” and clarifying “acute or chronic illness with systemic symptoms.”

Recalculating total time
The other methodology to capture the correct level of service is based on the total time, which includes both face-to-face time and non-face-to-face time that is specific to the patient’s total care for a particular day of service, but no longer needs to have a counseling component. It is the time personally spent assessing and managing the patient on the date of the encounter and includes:

  • Preparing to see the patient (e.g., review of tests)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests and procedures
  • Referring and communicating with other healthcare professionals (when not separately reported)
  • Documenting clinical information in the electronic or other health record
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • Care coordination (not separately reported)

While this is a CMS change only, we at Salud will be monitoring the commercial payers closely to see if they adopt the new methodology, and you should too. Also, you must keep in mind that it impacts only a few of the E&M services, and there will still be a need to follow the current existing guidelines for other types of E&M services, so there will potentially be dual rules dependent upon payer and setting.

Different providers will be impacted differently. Those who provide most services in an inpatient setting, such as hospitalists and intensivists, will see no change, while providers that function nearly exclusively in an outpatient or office setting will have significant change.

Understanding the changes, educating on the changes, and monitoring successful implementation will be necessary. Salud will be offering presentations on the E&M changes to industry groups and will certainly work with coding clients. The AMA offers tools and resources to help practices transition to the new reporting guidelines that take effect Jan. 1, 2021. That includes a checklist to help guide a practice through the E&M changes.

January 2021 is not far off, so the time to start training is now.