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Editor's e-Note
When Seema Verma, MPH, administrator of the Centers for Medicare & Medicaid Services, announced a plan last year to reduce the documentation burden of evaluation and management (E/M) services, many in health care rejoiced. It marked the first overhaul of E/M office visit documentation and coding in more than 25 years.

Now that the celebration has subsided, it’s time for the HIM world to take the necessary steps to get their houses in order by the time the revisions are deployed on January 1, 2021. This month’s E-News Exclusive offers a few pointers on how to get ready for the landmark day.

Lee DeOrio, editor
e-News Exclusive
Will E/M Changes Solve Documentation Woes in 2021?
By Stephanie Cecchini, CPC, CEMC, CEPFG

With no significant changes for 25 years, the advent of an updated payment method for coding office visits makes for juicy conference room chatter, dubious speculation, fear of the unknown, and … hope. But, what do evaluation and management (E/M) coding changes really mean for documentation requirements relief?

Up to now, Medicare, through well-meaning ideology or plain ignorance, punished physicians and nonphysician providers for decades with documentation rules that don’t coincide with their medical training, don’t aid (and dare I say, hinder) medical decision making, and rob 20 hours a week or more from patient care.

It’s a huge carrot to dangle by declaring a simple notation of time spent with the patient and what’s clinically relevant (according to the documenting provider) is all that is required. Providers, having been battered for years, are looking for the “gotcha” and the catch. So, has Medicare decided to reduce the administrative burden, or is there a devil in the details? To answer that question, let’s first recap the highlights of the changes, which are preliminarily scheduled to begin in 2021.

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Products & Services
Credit: Photo courtesy of ZHealth  
Documentation Solution Focuses on Cardiovascular Procedures
Nuance Cardiovascular CAPD is a new computer-assisted physician documentation, or CAPD, solution designed to help cardiologists improve the quality of complex documentation and the accuracy of reimbursement for cardiac catheterization procedures. Available through an exclusive partnership with ZHealth, the solution is based on patented algorithms built with ZHealth’s interventional documentation and coding expertise. Nuance Cardiovascular CAPD allows physicians to create complete, accurate documentation in real time and automate coding for cardiac catheterization procedures to accelerate the revenue cycle, improve documentation and coding efficiency, support compliant coding while eliminating the need for physician coding education, and improve patient and care team communications. Learn more »

AMA Playbook to Aid Record-Sharing With Patients
The American Medical Association has created the Patient Records Electronic Access Playbook, an online resource to direct physician practices through the legal complexities and operational challenges of providing patients with access to their digital health information. The four-part playbook compiles an extensive catalogue of educational information and reference resources with practical tips, case scenarios, and best practices for protecting patients’ privacy while empowering patients and their caregivers with convenient electronic access to their complete medical record. The playbook offers authoritative information to help medical practices better understand the pertinent laws and how they govern key topics for patient record sharing. These topics include amounts and types of information, forms and formats for sharing records, patient requests and involvement of third parties, timing for record request fulfillment, denial of record request access, permissible charges, and confidentiality of substance use disorder records. To help medical practices integrate legal compliance with patient care operations, the playbook offers a set of steps to make the fulfillment of patient record requests clearer and more efficient. Learn more »

Sam’s Club Launches Pilot to Make Health Care More Affordable
Sam’s Club has launched the Care Accelerator, an innovative pilot that offers members health care solutions at affordable cost. Care Accelerator is a series of bundled health care services that come with fixed, transparent prices for some of the most common primary care, dental, optical, and alternative medicine services. Members can choose from one of four bundles ranging from $50 to $240 per year. Each bundle offers free prescriptions on certain generic medications. They also offer opportunities to save on dental services with a trusted network of providers through Humana, on unlimited telehealth for only $1 per visit through 98point6, and on vision exams and eyewear. The family bundle, which covers up to six family members, also includes access to preventive screening for early detection of heart disease and diabetes; discounts on chiropractic, massage therapy, and acupuncture services; and a 10% discount on hearing aids. The program is currently available to members in Michigan, Pennsylvania, and North Carolina, with the potential to expand to all members in the future. Learn more »

Health Tool Streamlines Data Extraction From EHRs
Zynx Health has released Import Manager, a tool that delivers streamlined data importing from Cerner EHR systems to Zynx Health’s Knowledge Analyzer knowledge management solution. Specifically, Import Manager’s functionality enables health care organizations to extend the value of their Cerner EHRs by streamlining the import of PowerPlans (Cerner order sets) into Zynx Knowledge Analyzer. Previously, importing PowerPlans into Knowledge Analyzer required several manual processes. With Import Manager, Cerner EHR users have a new tool that simplifies and speeds the import of PowerPlans with increased accuracy and features the enhanced display of PowerPlans within Knowledge Analyzer. Learn more »
Ask the Expert
Have a coding or documentation question? Get an expert answer by sending an email to

This month’s selection:
How would you code neurocognitive disorder?

Name Withheld by Request

Neurogenic disorder, unspecified codes to R41.9

The answer to this depends on the specificity of the documentation; If the disorder is Major or Minor, then there would need to be additional information searched in the chart to lead to the specified code. If neurocognitive disorder is not specified, the assigned code would be R419.

— Trudy Alward, CCS, is senior auditor/coder at the Coding Services Group.

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Industry Insight
Study Evaluates Whether CDS Can Prevent Medication-Prescribing Errors

Prescription drug errors are a leading source of harm in health care, resulting in substantial morbidity, mortality, and health care costs estimated at more than $20 billion annually in the United States.

Currently, clinical decision support (CDS) alerting tools—computerized alerts and reminders—are widely used to identify and reduce medication errors. However, CDS systems have a variety of limitations, including that they are rule based and can identify only medication errors that have been previously identified and programmed into the alerting logic.

A new study published in the January 2020 issue of The Joint Commission Journal on Quality and Patient Safety used retrospective data to evaluate the ability of a machine learning system—a platform that applies and automates advanced machine learning algorithms—to identify and prevent medication prescribing errors not previously identified by and programmed into the existing CDS system.

Read more »
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