Author: Doreen DeGroff
On January 1st, 2021, the American Medical Association (AMA) is set to roll out a new set of Evaluation and Management guidelines. This is part of the CMS Paperwork Over Patients Act to reduce the administrative burden and ambiguity related to medical documentation and coding. Here, we’ll lay out our time-tested approach to addressing coding changes to help you hit the ground running with these changes when the New Year arrives.
Analyze First, System Last
Typically, the first question we hear from EHR clients is “How is the system going to handle this?” While this is certainly a valid question, the first question step should be to define a process for implementing these changes. The approach we follow for our EHR solution at CereCore, as well as for our clients, is Analyze, Policy, Educate, and System (APES). While this approach is internally developed, it is a time-tested method that our team has found to make the overall process easier and more effective.
A – Analyze
This three-step process helps organize the process and define the impacts of some of the coding changes.
- First, analyze the new requirements. My method for this is to write out the 5 Ws. If we apply this method to the new requirement, for example:
- Who: These changes apply only to office visits and other outpatient visits for physicians.
- What: This applies to:
- The current 5 Levels of care codes that providers use to bill for office visits and outpatient care.
- Level of Care Code 99201 will be eliminated.
- Either Medical Decision Making or Time will drive the level of Code selection. New time thresholds have been developed that are associated with the Level of Care Codes. This works with the new definition of total time spent. A new E&M code has been created for prolonged services in 15-minute increments. History and physical exams will no longer be a part of the Level of Code assignment decision.
- This does not negate the need to document what is appropriate for the patient regarding the H&P Exam.
- When: These new codes and code selection guidelines are effective 1/1/2021.
- Where: There is no longer a need to document the medical necessity for a home visit instead of an office visit, however this encompasses office, home and other outpatient visits.
- How: It’s going to be important to understand exactly what the new requirements say and how to apply the new methods that drive the code selection process.
- Analyze what you do today.
- Analyze the impact of what you today, including:
- Audit current documents.
- Review revenue/payment impact for each E&M code.
- Review your contracts with other 3rd party payers and identify who will be implementing the new guidelines.
- Look at ways you can continue to monitor E&M code use and documentation moving forward.
- Review your Policy and Procedures, bylaws, and other guidelines to see what you currently have in place will be impacted by the changes.
For level 2 through 5 visits, you need to choose between using the current framework, Medical Decision Making (MDM), or time:
- When time is used, practitioners document the medical necessity of the visit and the time spent face to face with the beneficiary. For code levels 2 through 4 if practitioners need to spend additional time with the patient an ‘extended visit’ add on code can be utilized.
- The use of the current framework or MDM will require the supporting documentation currently associated with level 2 visits.
How do some of these changes impact the documentation workflow? If the decision is to modify documentation recorded during the visit, can the provider easily access this information in other parts of the record for reference during the visit? Providers will no longer be required to reenter information recorded by office ancillary staff and/or the patient. It will be important that this information is accessible for the provider’s review and perhaps even melded into the documentation and they can review and verify.
Practitioners also need to look at the information that may no longer be required for applying the correct visit code but may be needed for other regulatory and quality initiatives. Finding the right balance to document the minimum necessary to meet all criteria may be the toughest part in applying these new changes.
P – Policy
Here is where you take what you learned during your analysis and define what this means to your organization. How will you apply the guidelines within your provider practices and what Policies and Procedures, Bylaws and other items need to be updated?
Based on your business decisions, make the required updates.
E – Educate (and collaborate)
Education of your stakeholders and users is not only a continuous process but also a collaborative one, especially as it relates to implementing changes to business processes.
- Educate all stakeholders on the new requirements and gather their questions, concerns, and feedback. This collaboration will help make sure you are creating policies that address the needs of the user-base while complying with the guidelines of the law.
- When a new facility policy is created, provide another opportunity to gather stakeholder feedback, concerns, and suggestions before rollout. This can identify issues/gaps before system-wide rollout.
- Educate all users on system changes that will be deployed.
- It is also key to create an ongoing education program. This will help you monitor and evaluate the impact of the changes, maintain consistency in following the new processes, and increase overall adoption regarding the changes.
S – System
Once you understand the new regulation, how it impacts your facility, and what policy and procedure is best for compliance, then it is time to look at the system and ensure it can support your decisions in the most efficient, user-friendly manner.
- Reviewing the current templates and defining necessary updates may be all that is needed. It is telling to test the new templates and evaluate if they meet the expectations of the actual users. This test will further cement the appropriateness of your decisions, policy changes, and system build.
- Develop reports that can track E&M usage by provider and other ways to audit how the process is working. These can also assist you once LIVE to determine where education, policies, and changes could further optimize the process.
The CMS Patients over Paperwork Act will continue to evolve after the next phase in the new 2021 year. I hope the above tips are beneficial in defining a process that supports your facility through these changes and beyond.
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