The documentation guidelines set forth by the Centers for Medicare & Medicaid Services (CMS) for evaluation and management (E/M) services, established 20 years ago, do little to support patient care. Instead, they serve more as a scoring system to justify a level of billing (e.g., level 3, 4, or 5), rather than helping physicians diagnose, manage, and treat patients. Adherence to E/M documentation guidelines consumes a significant amount of physician time and does not reflect the actual work of physicians.
In response to stakeholder complaints, CMS Administrator Seema Verma launched the Patients Over Paperwork initiative in 2017 in accord with President Donald J. Trump’s executive order that directed federal agencies to cut red tape. In response, in 2018, CMS proposed revisions to the E/M rules, which went into effect on Jan. 1, 2019, including the following:
- For an outpatient visit with an established patient, a provider can record only what has changed since the last visit and need not re-record the history and exam if there is documentation that the practitioner reviewed and updated the information in the medical record.
- For an outpatient visit with a new or established patient, the billing provider does not need to redocument a chief complaint or history that was recorded in the medical record by ancillary staff. This includes the chief complaint and any other part of the history, history of present illness, past family social history, and review of systems. The billing provider can review the information and update as necessary.
- The billing provider should document in the medical record that information entered by ancillary staff or the patient has been reviewed.
More extensive changes will go into effect on Jan. 1, 2021, including:
- extensive E/M guideline additions, revisions, and restructuring
- deletion of code 99201 and revision of codes 99202–99215
- code level selection should be based on:
- medical decision-making (MDM) or total time on the date of the encounter
- creation of a 15-minute prolonged service code to be reported only when the visit is based on time and after the total time of the highest-level service (e.g., 99205, 99215) has been exceeded.
- Note: Although the history and physical exam elements are recorded, they do not factor into the level of service.
Current Procedural Terminology (CPT) changes
The American Medical Association (AMA) has created new CPT code descriptors for office or other outpatient services (new and established patients) that can be based upon the level of MDM or the time spent by the provider on the encounter.
For each code descriptor for these services in CPT, all references to level of history and physical examination are removed. Instead, it is specified that there must be a medically appropriate history and/or physical examination and a specified level of MDM.
Time as a determinant of level of service
For providers who wish to bill by time, the length of time corresponding to each level of visit is specified. Note that the current time rules for coding apply when counseling and/or coordination of care dominates (more than 50 percent) the encounter and includes only face-to-face time in the office. Starting in 2021, providers who wish to code by time spent may include all related activities on the day of encounter.
MDM as the prime determinant of level of service
It is expected that the conversion to MDM as a basis for the level of coding will require some planning and preparation on the part of qualified healthcare providers. MDM has always been part of the algorithm for choosing a level of service but will now be the sole determinant of level of service (unless the provider intends to bill based on time).
MDM in 2021 will be based on:
- number and complexity of problems addressed
- amount and/or complexity of data reviewed and analyzed
- risk of complications and/or morbidity or mortality
Number and complexity of problems addressed at the encounter
The greater the number and complexity of problems addressed at the encounter, the higher the applicable level of decision-making. This ranges from straightforward to low, moderate, and high.
Several specific problem level options are listed. They range from self-limited or minor problem to acute or chronic illness or injury that poses a threat to life or bodily function.
For many physicians, it may not be clear what constitutes a “self-limited or minor problem.” For this reason, specific definitions have been developed by the AMA and CPT so as to limit confusion. These will be published in CPT for 2021 but are available now for providers to review.
Amount and/or complexity of data to be reviewed and analyzed
This category attempts to quantify the amount of data, efforts to gather data, and communications utilized to evaluate a patient. Collection of more data leads to a higher level of MDM. Levels include minimal or none, limited, moderate, and extensive. Data are divided into three categories:
- category 1: tests, documents, orders, and review of prior external note(s) from each unique source or independent historian(s)—each unique test, order, or document is counted to meet a threshold number
- category 2: independent interpretation of tests not reported separately
- category 3: discussion of management or test interpretation with external physician/other qualified healthcare provider/appropriate source (not reported separately)
To determine amount and complexity of data, it may be helpful to read the definitions of terms, which are available at the AMA website.
Risk of complications and/or morbidity or mortality
This is an assessment of the relative danger of patient management—whether from treatment or further work-up. Levels are minimal, low, moderate, and high. Some treatments are relatively risk-free, such as over-the-counter medicines and dressing changes. Some are highly risky, such as a decision about emergency major surgery.
To estimate the risk of complications, morbidity, or mortality, it may be helpful to become familiar with the definitions—for example, risk, morbidity, social determinants of health, and drug therapy requiring intensive monitoring for toxicity. The definitions are available on the AMA website.
Once the level of the presenting problem is established, data are reviewed, and risk management is determined, the overall level of MDM can be determined. To qualify for a particular level of MDM, two of the three elements for that level of decision-making must be met or exceeded. That will determine the level of E/M service.
It is clear that this new method of determining the level of E/M service will require major changes to physician behavior and documentation. Providers will need detailed instructions, system changes, and practice using the new E/M codes.
These changes apply only to outpatient visits, so don’t throw away note templates. The old system of documentation is still required for consultations, emergency room visits, and inpatient visits.
The old system relied on documentation of a series of bullet points for history and physical exam to support a level of service. The new system for 2021 relies on documentation of bullet points for diagnoses or treatment options, amount and complexity of data reviewed, and risk of complications. It is unclear whether these changes will actually be an “improvement.”
Although CMS will implement increased work values for E/M codes performed in the outpatient setting, the increases will not be applied to visits bundled into 10- and 90-day global procedure codes.
What can be done to prepare for these changes?
- Learn about the proposed changes by reading online, attending coding courses, and watching webinars. AAOS will offer educational materials, webinars, and courses to help members adopt the new E/M coding changes.
- Determine whether your electronic health record templates need to be changed to de-emphasize bullet points for history and exam and emphasize elements of MDM.
- Become familiar with the definitions of problem types, risks, and other elements of services that will be needed to substantiate levels of MDM.
- Learn to routinely document items within notes that will be used to score MDM, including ordering tests or X-rays, interpreting tests and X-rays, requesting review of outside documents, having discussions with other healthcare providers, and using independent historians aside from the patient.
- Test-drive some notes to see how they would score using the new MDM parameters.
Learn more at https://bit.ly/2TiBjSb.
R. Dale Blasier, MD, FRCS(C), MBA, FAAOS, is a practicing pediatric orthopaedic surgeon at the University of Arkansas for Medical Sciences in Little Rock, Ark. He is a member of the AAOS Committee on Coding, Coverage, and Reimbursement.