Bill Clinton was in the White House, OJ Simpson was in a courthouse, the Dow hit 4000 for the first time. Microsoft hit the start button on Windows 95, and CMS issued some major changes to the way doctors get reimbursed for outpatient evaluation and management (E/M) services.
Much has changed in our world in the last quarter century, but E/M reporting and coding hasn’t been one of them… until now.
On January 1, 2021, revised E/M coding guidelines go into effect with major implications for compliance, false claims, and reimbursements. But despite the fact that the changes have been in the works for several years, smaller independent medical practices may not be prepared, and up to 40% of their revenue may be at risk.
CMS had decided to make these changes as part of its “patients over paperwork” initiative with the American Medical Association (AMA). To that end, medical record documentation is being simplified, with the focus on reducing administrative burden and creating claims that are resource-based. The AMA says the E/M office-visit overhaul:
- Eliminates history and physical exam as elements for code selection. While significant to both visit time and medical decision-making, these elements alone should not determine a visit’s code level.
- Allows physicians to choose whether their documentation is based on medical decision-making or total time. This builds on the movement to better recognize the work involved in non-face-to-face services like care coordination.
- Changes medical decision-making criteria to move away from simply adding up tasks to instead focus on tasks that affect the management of a patient’s condition.
In short, the old coding method that required a full medical history and examination are now reduced to only that which is medically appropriate for the claim. Further, the physician can now choose between medical decision making or time on the claim. Previously, time-based billing was limited to face to face time on the date of the visit as long as more than 50% of the visit was for counseling and/or care coordination.
Coding is now driven by the new table of medical decision making or time. Time is no longer limited to the date of the encounter or face to face consultation.
What does this mean for the medical practice?
- Current code calculators embedded in many EMR systems need to be disabled for Outpatient and Office visits effective 1/1/21. However, current coding remains for inpatient services.
- New EMR Templates need to be created and installed for the new E/M coding changes.
- An evaluation should be conducted for those involved in telehealth to ensure that coding for current Telehealth visits complies with the new E/M coding for outpatient coding.
- Training and education of clinicians needs to take place on new coding procedures and the requirement differences between outpatient and inpatient services.
- Workflows need to be revised to accommodate the coding changes.
Independent medical practices have some work to do before the first of the year. A comparative financial analysis should be conducted to determine the impact on an individual practice and a team of internal and external advisors should be put together to create an implementation plan. That plan should include discussions with the EMR provider on the timing and status of system changes, the revising of EMR templates, and most importantly, an update to practice protocols, compliance plans and workflows particularly related to fraud and abuse law infractions, malpractice liability and insurance coverage.
So much has changed in our world in the last 25 years (let alone in the last 10 months!). Practices would be wise not to get caught on the wrong side of history.