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April 2020

Coding Corner: E/M Changes Afoot
By Barbara Aubry, RN, CPC, CPMA, AAPC Fellow, CHCQM, FABQAURP
For The Record
Vol. 32 No. 3 P. 8

For years, evaluation and management (E/M) services coding has been based on either the 1995 or the 1997 E/M coding guidelines of the American Medical Association (AMA). Over the past two decades, the health care industry recognized that updates were needed, but change can be time consuming and costly, as both physicians and professional coders would require training to learn and implement new rules, coding resources would have to be updated, and many payer policy rules would need to be rewritten or at least edited.

As a result, the E/M guidelines remained fixed, even though many in the industry were dissatisfied with the status quo.

Enter the EHR Era
While the EHR brought many benefits, physicians learned quickly that the technology was not necessarily built to support their workflow or documentation process. In documenting for each E/M encounter, providers were faced with an EHR built largely to support reimbursement requirements. Without clinician input on the design, an EHR template documenting a follow-up E/M visit for a specific chief complaint of an upper respiratory infection, for example, required a complete review of systems; a past medical, family, and social history; or a full system examination.

Physicians soon realized that filling in the required blanks of the E/M template took more time than previously needed to properly document a service. Clinicians increasingly complained of the burden of administrative tasks, with many spending eight hours a day in patient care and another four to five hours in the evenings completing EHR documentation.

The result has been physician burnout, a decline in clinicians working in clinical areas, and early retirement for many who no longer enjoy the practice of medicine.

2021 E/M Changes
The AMA listened to physician complaints and recently worked in concert with the Centers for Medicare & Medicaid Services (CMS) to reduce the amount of administrative work required of physicians in documenting E/M services. Office visits represent nearly $23 billion in Medicare spending. The time needed to document these services in the EHR has grown to reflect many hours of physician administrative work.

In the hopes that a reduction in administrative work will help alleviate physician stress and burnout, both the AMA and CMS have focused on reducing the documentation time burden for services frequently provided.

The revised guidelines were developed by a work group assembled by the AMA representing its CPT Editorial Panel and the AMA/Specialty Society Relative Value Scale Update Committee (RUC). Peter Hollmann, MD, a former chair of the CPT Editorial Panel, and Barbara Levy, MD, a former RUC chair, led the work group. The goal was to simplify the E/M requirements, make them clinically relevant, and reduce excessive documentation burden.

Key elements of the E/M office visit overhaul include the following:

• History and physical exams were eliminated as elements for code selection. While significant to both visit time and medical decision making (MDM), these elements alone should not determine a visit’s code level.

• Physicians are now allowed to choose whether their documentation is based on MDM or total time, which recognizes the work involved in non–face-to-face services such as care coordination.

• MDM criteria were modified to move away from simply adding up tasks to focus on tasks that affect the management of a patient’s condition.

• The new E/M office visit code selection criteria remove complex counting systems for history, exam, and data that sometimes varied by payer. Now, physicians can decide whether to code by the total time—including non–patient-facing activities on the day of service—or MDM related to the visit.

• Ambiguous terms such as “mild” were removed, and previously ambiguous concepts, such as “acute or chronic illness with systemic symptoms,” were clearly defined.

• CPT code 99201 was deleted because 99201 and 99202 are both straightforward MDM and differentiated only by history and exam elements.

• A shorter prolonged services code was created to capture physician/qualified health care professional time in 15-minute increments. This code would be reported only with 99205 and 99215 and be used when time was the primary basis for code selection.

In August 2019, CMS held a conference call for those interested in the E/M updates during which the agency addressed its intention to create G codes to be used in 2021 to “represent additional resources associated with primary care.”

CMS went on to explain further: “In the CY 2019 PFS Final Rule, we finalized two HCPCS add-on G-codes describing additional resources associated with primary care and certain types of nonprocedural specialty visits, for CY 2021. However, we understand from previous comments and ongoing engagement with stakeholders that the add-on code(s) should be easy to understand and report for purposes of medical documentation and billing. We also want to maintain clarity that the add-on code is not intended to reflect a difference in payment by specialty, but rather recognition of a different per-visit resource cost based on the kinds of care practitioners provide, regardless of Medicare enrollment specialty. We are therefore proposing a single add-on code that describes ongoing primary care and/or ongoing medical care related to a single, serious, or complex chronic condition billable with every office/outpatient E/M visit meeting these criteria.”

(The slides from the CMS presentation can be viewed at www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2019-08-12-PFS-Presentation.pdf.)

The AMA also released a table that explains the new calculation process to determine MDM and code choice.

For those familiar with E/M coding, a notable change is the shift of prescription drug management from a level three to a level four code. The table includes instructions on actions to take when considering the number and complexity of problems addressed (at the encounter), amount and/or complexity of data to be reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management. Scoring and points have largely been reduced.

The table, which is appropriate to use for CPT codes 99202/99212, 99203/99213, 99204/99214, and 99205/99215, can be a helpful training tool for physicians and coders.

The table can be accessed at www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf.

Implementing E/M Changes
The AMA has made suggestions to assist practices in implementation of the E/M changes, such as choosing a project lead responsible for training, revising internal policies and procedures, updating the internal compliance plan, and tracking financials to determine how the changes impact revenue. In addition, the AMA is making resources available to help practices determine when to engage an external advisor to assist with business issues.

Even though E/M documentation requirements have become more flexible, careful documentation is still critical. Practices should check with payers or large employer medical group plans to determine the requirements for documenting additional information above and beyond the new E/M office coding guidelines. The AMA is working to help educate payers and others on the importance of the burden reduction potential of the new codes.

Be sure vendors and all supporting entities used by the practice are prepared to comply with the January 1, 2021, effective date and confirm that EHR and billing vendors are on schedule to implement the corresponding changes to their systems. This is essential for effective compliance.

Along with checking systems, consider the use of expert external coding staff to assist with the transition and to support internal staff while they learn the new rules. Coding consultants are available to train and support staff on site and many also offer virtual coding training seminars for both physicians and internal coders, allowing online learning as schedules permit. Learning and practice can be supplemented by access to an in-person expert as questions arise and additional on-site training can be customized based on the needs of the practice and the issues encountered.

The simplified documentation requirements better reflect the general work process of physicians using EHRs but, like most changes, physicians and coders will need time and training to become accustomed to the new E/M rules. A long-standing tenet of clinical documentation is the importance of properly recording enough information so another physician can assume care if necessary, with a full understanding of the patient’s chief complaint, the treatment plan, and the outcome of either treatment or work-up.

The streamlined E/M documentation guidelines support this tenet and, at the same time, have the potential to ease the administrative burden on physicians, reducing burnout and creating more time for patient care.

— Barbara Aubry, RN, CPC, CPMA, AAPC Fellow, CHCQM, FABQAURP, is a senior regulatory analyst for 3M Health Information Systems.