E/M and coding changes in the past few months have led many people to wonder what kind of changes are going to happen with outpatient documentation. Many changes have been made to the AMA Current Procedural Terminology (CPT) code set, which are predicted to only apply to outpatient and office settings, and not inpatient, home care, or nursing home E/M.

These changes are going to reduce the need for auditing, which is going to reduce physician burnout and “note bloat.” This aims not only to help physicians but also to guarantee that E/M service payments are resource based on to streamline the process.

What Are Some of the Coding Changes You Should Know About?

Some of the important coding changes to keep in mind are that the components for code selection have been reduced to two, which help with medical decision making (MDM) and total time on the day of the encounter.

Some of the changes that you should be aware of with regards to MRM coding are as follows.

  • The amount of and the complexity of problems that can be discussed in an encounter have been affected, which means that many of the diagnoses that a patient has received does not have to be mentioned in the document apart from the ones that are discussed or addressed in that particular visit.
  • The amount of and the complexity of the data that is reviewed and studied has been changed. This means that much of the repetitive and redundant data that healthcare providers previously had to enter into their documents are no longer required. Unless that data is relevant to their visit, it does not have to be entered.
  • The risks and complications, as well as the morbidity of patient management have been affected. This refers to the social reasons why a healthcare provider can decide not to admit a patient or make changes to their treatment.

Previously, social determinants were not included as a reason in the documentation. These kinds of social determinants include things such as whether it is viable for a patient to undergo certain treatments and whether they have the transportation means to undergo that treatment at the clinic.

Some of the changes that you should be aware of with regards to E/M time are as follows.

Previously, E/M time meant that healthcare providers and doctors had to mention the amount of time that they spent engaging in in-person contact with a patient. However, because of the coronavirus and because of advancements and changes in medical practices, this time also includes time that doctors spend not in-person on the day of the encounter.

When working with codes, time was an important criterion which determines which kinds of codes needed to be sleeved based on ranges of minutes for both new and old patients.

The option to mention time regardless of whether the care and treatment decided during the visit is determined by previous counseling or discussion before the actual visit. Previously, the option to mention time in these situations was not available.

The expectation is that MDM codes are supposed to be the most frequently used by physicians, however, the codes related to time are a better representation of how much time each patient encounter takes up, even when these encounters are rated lower on the MDM scale.

Because they take up a large amount of time and energy by the physician, regardless of whether they spend that time discussing medical untruths or clearing a misunderstanding in the medical world, they are considered a part of the time-related coding.

Some other aspects of the time-related coding include the time that physicians spend reviewing and assessing the tests that belong to a patient before the patient comes in for the visit. It also includes the time they spend talking to a patient’s family and caretakers with regards to their condition or the information they need in order to take better care of them.

It also includes discussing test results with a patient through the telephone. In fact, this time is also inclusive of the time that physicians spend ordering certain tests or procedures to be performed for their patients and the time they spend working at home towards a cause related to their patients.

Other Changes to Coding

Some other important coding changes include the reduction of the history and physical exams that physicians had to previously include in their documentation. These were previously key elements in deciding the code level of a visit, and have now been moved to make space for more determinants.

There are going to be a larger number of payment packages with the onset of added codes, as they are not relevant for every department. For example, these codes lead to more payment bundles for departments such as maternity care, but are not going to have a significant influence in surgical global payment bundles.

While the changes are going to impact the billing process and how insurance companies work with the healthcare facilities, as well as how different inpatient and outpatient visits are understood, they were made with the intention to make life easier for healthcare providers in terms of the time they spend in documentation.

It also helps to notice and pay tribute to the time they spend in tasks that were conventionally not part of the documentation system, such as time spent working on counseling and working at home. With telemedicine and telehealth practices on the rise, it is necessary that proper payment and billing procedures are taken to reduce burnout and adjust to the changing times.

Final Words

These changes and E/M office visit guidelines are set to take place from January 1st, 2021. It is encouraged for all healthcare facilities and physicians to get a clearer idea before then.

If you need help with your medical billing, payment, and collection, get in touch with us for our full services. We help take away from your work load when it comes to payments and documentation, so you have more time to devote to patient care.

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