04 Mar Will 2021 Bring a Reduction in Your Documentation Burden?

We’ve discussed the changes in Evaluation and Management (E/M) coding that will go into effect in January 2021 before.

The AMA is asserting that these shifts in documentation requirements will reduce the scourge of “note bloat” and allow for more streamlined documents-3816835_650charting for clinicians:

“The whole point was to have people not document stuff that was not necessary, not relevant to the clinical management of the patient,” according to Dr. Peter Hollmann, a former chair of the CPT Editorial Panel and current lead of an E/M work group for the AMA.

Beginning in 2021, the history (HPI) and physical exam should only be performed and documented as medically appropriate, and these two elements of a visit will no longer be considered as factors when determining a level of service, eliminating the need for counting systems.

Instead, an E/M level will be based on either documented medical decision making (MDM), or the time spent with the patient.

Dr. Barbara Levy, a former AMA committee chair, states: “If coding for medical decision-making, it’s about clearly stating what you’re treating and that’s not difficult for us because that’s what we’re doing in the encounter. The most important thing is to document what you’re actually taking care of and not just listing all the other problems a patient has but you’re not dealing with that day.”

The new guidelines also expand the requirements for being able to use time as the determining factor for a level of service. Under the current leveling system, over half the visit has to be spent face-to-face with the patient counseling and/or coordinating care in order to bill based on time.

Under the new 2021 guidelines, the time spent can include:

  • Reviewing tests in preparation of a patient visit.
  • Obtaining and/or reviewing separately obtained history.
  • Performing a medically necessary appropriate examination and/or evaluation.
  • Counseling and educating the patient, family or caregiver.
  • Ordering medications, tests or procedures.

As long as the time spent is clearly documented, and the activities enumerated.

That, as always, is the trick. Only time will tell if payors are willing to be reasonable in setting expectations on the amount of detail that has to be documented to be considered “supportive” of a particular level of service. We will, of course, be updating you as we find out more information.

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