Strategies to Guide Proper Reporting of E/M Service levels in 2021

As the COVID-19 pandemic rages on, it’s even more glaring how much help practices need in aligning their processes to provide better patient care. Physicians have to document the amountof work involved in each patient encounter, according to guidelines written over 20 years ago. This task is time-consuming and challenging. Thankfully the newest changes to the coding guidelines on outpatient evaluation and management (E/M) services by the Centers for Medicare and Medicaid (CMS) aim to align coding practices with patient care.

According to the new modifications, providers will now select E/M codes based on the level of medical decision-making (MDM) or the total time performing the service on the day of the encounter. While they will no longer use history and examination for E/M code selection, providers are still expected to document all findings pertinent to a visit. The previous time rules for E/M codes apply when in-office counseling or care coordination accounts for more than 50 percent of an encounter. However, starting in 2021, providers who wish to code by time spent may include all related activities on the day of the encounter.

As practices transition to this new leveling methodology, their providers must adapt to the changes. Less reliance on history and exam in determining E/M codes should not reduce the facts supporting a given diagnosis. Rather it enables them to avoid generic documentation to refocus on supporting the necessity of the diagnosis. ACOs and other organizations should provide member practices – and their physician, non-physician, and coding staff, with targeted education, and tools to address these newest changes.

To improve E/M service-level selection, providers need to know which services are separately reportable and understand all defined terms, especially those related to the new changes. MDM will be the determining factor in E/M levels based on the documentation of the following:

  • number and complexity of problems addressed
  • The amount and complexity of data reviewed
  • risk of complications, morbidity, or mortality (including Social Determinants of Health)

For many physicians, it is not clear what constitutes a “self-limited or minor problem.” Hence specific definitions have been developed to limit confusion. Time-based reporting is still a useful option to choose a level of service, whether counseling or coordination of care dominates the services. The new revisions address confusion around increments of time. So, it’s essential to know when services are rendered and the total time spent on each activity. Eligible time includes both the face-to-face and non-face-to-face time that the physician personally spends before, during, and after the visit on that same day.

Specific examples include (when not separately reportable):

  • Care coordination
  • Counseling and educating the patient, family, or caregiver
  • Documenting clinical information in health records (electronic or otherwise)
  • Independently interpreting and communicating results to the patient, family, or caregiver
  • Getting or reviewing separately obtained history
  • Ordering medications, tests, or procedures
  • Performing a medically appropriate exam or evaluation
  • Preparing to see the patient (e.g., reviewing tests)
  • Referrals and communication with other health care professionals

Another critical effect of the changes is a greater emphasis on the documenting of Social Determinants of Health (SDoH). On occasion, proper documentation of SDoH and how they significantly impact diagnosis or treatment could decide if an E/M service’s MDM level is low or moderate.Additionally, it’s important to remember that proper ICD-10-CM coding of external factors (Z codes) is critical in meeting theMerit-Based Incentive Payment Program (MIPS)reporting requirements.

Regardless of which method is used for service level reporting, providers should pay close attention to their documentation of SDoH since these external factors impact both MDM and time spent in counseling and care coordination activities. The new rules strive to align coding practices with the way providers think. The goal is to decrease unnecessary documentation not needed for patient care while improving reliance on medical necessity for reimbursement. Every provider should be taking advantage of this. At a minimum, organizations should identify providers who could benefit from education. With the guided implementation of E/M code guidelines, organizations can free their medical practices from unnecessary administrative tasks.

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