DO YOUR TEMPLATES NEED A TUNEUP?
In an active year of interim rulemaking to accommodate flexibilities during the COVID-19 public health emergency, the Centers for Medicare and Medicaid Services (“CMS”) adopted new documentation requirements for reporting office and outpatient E&M services under the Medicare Physician Fee Schedule (“MPFS”) [1]. January 2021 marked a fundamental transformation, arguably the most significant change in 25 years to the documentation requirements of E&M services.
Selection of office/outpatient E&M levels 2 through 5 are now based on either the level of Medical Decision Making (“MDM”) utilizing the modified American Medical Association (“AMA”) table, or the total time personally spent by the practitioner on the day of the visit. For physicians in this environment, it requires a mind-shift, unraveling habits focused on accommodating previously stringent documentation requirements. Intended to simplify and allow for greater flexibility, physician understanding of the new requirements, in particular, the new MDM table, is imperative to ensure documentation aligns with levels of service reported.
Due to confusion surrounding the changes, on March 9th , the AMA published technical corrections to the office and other outpatient E&M Guidelines. Below we highlight some elements clarified, as well as some observations and insights based on our auditing during this transition.
HISTORY AND PHYSICAL EXAM
Revised coding guidelines instruct providers to record a medically appropriate history and physical examination (“H&P”), no longer requiring particular components or a certain number of elements. While modifications to office/outpatient E&M services allow greater flexibility, relaxed documentation requirements should not be interpreted to mean that the H&P are optional to document. On the contrary, elements of the H&P are vital to supporting medical necessity of the visit, which remains the overarching criteria for payment.
Unique elements contained within the patient history, review of systems and physical exam are integral to conveying complexity of problems addressed during the visit. A well-documented and thorough history of present illness (“HPI”) can substantiate the nature of the presenting problems detailing symptoms, context of the injury, exacerbation of illness, disease progression or even side effects of treatment.
With the advent of electronic health records (“EHR”), providers came to rely heavily on templates within their progress notes to meet necessary criteria for H&P elements. Templates remain a valuable tool within the EHR, though levels of E&M service will not be predicated on complying with particular H&P elements. We caution providers, that unamended templates can create incongruencies in a progress note and potentially undermine medical necessity.
MEDICAL DECISION MAKING
Relaxing documentation requirements surrounding H&Ps shifts the emphasis to the physician’s MDM. With greater focus on their cognitive efforts, articulating detail surrounding the assessment and plan, differential diagnoses, alternative treatments, and risk therein is vital. In this regard, the 2021 Table of Medical Decision Making serves as a guide encompassing three elements:
Number and Complexity of Problems Addressed
Amount and/or Complexity of Data to be Reviewed and Analyzed
Risk of Complications and/or Morbidity or Mortality of Patient Management
Documentation needs to satisfy two out of the three above-listed components in support of a given service level. We take a deeper dive into each of the three elements of MDM below:
1. Number and Complexity of Problems Addressed
A departure from the prior point system where providers received more credit for a new versus established problem, physicians must capture sufficient detail to characterize the complexity of a problem. In acute treatment settings such as urgent care or walk-in clinics, pediatrics, and primary care settings, this can be particularly impactful to the overall level of service. Assigning more weight to a presenting problem simply because it is new to the patient or practitioner, could present risk. No longer can practitioners rely on greater valuation of a problem simply because it is new.
Increased detail describing the nature of an illness or injury will help frame the complexity. Failure to document context or omitting how the patient’s current presentation may point to a more concerning or even prior disease process can potentially limit the assigned complexity. Expanding upon how the patient’s current presentation may be a manifestation of, or related to, a previously established condition can elevate the complexity. The complexity of a patient with back pain, for example, who has a history of disc displacement and prior surgery is quite different than a patient who presents with back pain and no relevant history.
Relative to the number of problems addressed, active problem lists carried forward detailing an array of comorbidities is not sufficient. The AMA is rather prescriptive in this regard:
“Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E&M service unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed of the risk of complications and/or morbidity or mortality of patient management.” [2]
In other words, the onus is on the provider to be explicit in articulating how a particular problem or disease affects the assessment and management of the patient. If the patient’s past medical history impacts decision making, the progress note should unequivocally reflect this. While the provider’s cognitive thought process may account for this, unless it is evident within the documentation, credit may not be given for the added complexity or an additional problem addressed. Co-morbidities pulled forward or captured as part of a templated progress note are credited only if the specific condition is explicitly referenced in the context of the current management decisions, and contributes toward overall complexity of MDM.
2. Amount and/or Complexity of Data to be Reviewed and Analyzed
Reviewing and ordering diagnostic tests is foundational to evaluating and managing both acute and chronic illness as well as injuries. How this data is utilized by physicians in developing a treatment plan is vital to understanding what is expected under the new coding framework.
Under the 1995 and 1997 E&M guidelines, a provider was credited for their review of lab or diagnostic test results. While a template may prompt the physician to mark a laboratory result, cardiovascular or radiology study as reviewed within the progress note, the bar is higher now. Laboratory values and test results pulled into the progress notes are no longer sufficient to credit a physician for data review. Providers should take note to the addition of the word “analyzed” which is new to the 2021 coding guidance. To credit a provider for their analysis of a diagnostic test, reviewers will look to see how that impacts MDM. The analysis of the data needs to be evident and specifically incorporated into management of the problem(s) addressed during the encounter, as underscored by the AMA in the March 9th update. Simply put, analysis includes the process of using the data as part of the MDM. Omitting discussion of relevant lab results in the process of MDM, even if the result is negative, may impact the number of data elements credited and ultimately the level of E&M service. They further clarified that tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. If tests are ordered at a time other than during an E&M encounter, the test may be credited during the visit in which it is analyzed.
To be credited for an independent interpretation of a test, though, it is not expected that the provider’s interpretation conforms to the usual standards of a complete report as if the interpretation were separately reported. Rather, we would expect to see a summary of their impression. Simply commenting that images have been visualized is not sufficient. Though templates may allow a provider to indicate if images have been reviewed, this can be problematic if the template does not accommodate free text such that the provider is prompted to include his/her impression.
It is important to caveat that data analysis should not be credited for services separately reported. The AMA clarified:
“The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the level of E/M services when the professional interpretation of those test/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation but may be counted as ordered or reviewed for selecting an MDM Level .” [3]
The AMA explained in the recent update that diagnostic tests considered, yet not actually performed, may contribute toward data elements. If a patient requests a particular imaging study that the provider deems not necessary, for example, the provider may be credited toward MDM if his/her progress note is explicit relative to the lack of benefit to the patient. In a different scenario put forward, a documented decision to not proceed with testing that poses risk to the patient may also contribute to MDM. Ultimately, consideration relative to various testing options must be documented for the provider to be credited.
3. Risk of Complications and/or Morbidity or Mortality of Patient Management
In the recent technical corrections published, the AMA underscores an interesting distinction between the risk of a condition versus the risk of complication of patient management decisions made during an encounter. The latter is the third element used in selecting the level of MDM.
Conveying patient risk is an aspect of the E&M service which physicians tend to under document. While risk to the patient can sometimes be implied or inferred, physicians undervalue their expertise in this regard. Concerns relative to treatment options considered, selected, or even deferred are often not expressly recorded in the progress note. This is essential to communicating risk and, in turn, receiving proper credit toward MDM. Credit is only given for what is documented. This is also true for differential diagnoses and diagnostics. A practitioner articulating within the progress note how the particular patient may be vulnerable or otherwise compromised by possible management options selected, or those considered, is a requisite for being appropriately credited.
Lack of specificity in the assessment and plan may also be a costly omission. Comments such as “continue current treatment” are too vague relative to crediting for risk associated with patient management decisions. More detail is needed as the current treatment is not evident within the progress note.
Relative to risk of surgery, the AMA explained that the designation of minor or major surgery is based on the common meanings of such terms when used by trained clinicians. They clarified in the technical corrections that these terms are not defined by a surgical package classification. In other words, whether a procedure is valued with a 10- or 90- day global period does not alone determine risk. Rather, the AMA clarified that risk factors include those that are relevant to the patient and the specific procedure. While evidence-based risk calculators may be applied, they are not required in assessing and documenting patient and procedure risk.
As with the other components of MDM, templates can help guide providers with incorporating risk elements into progress notes. Social determinants of health, a new concept, can even be incorporated into a template, prompting practitioners to solicit questions of the patient during the encounter. Questions surrounding access to food, housing, transportation, social connections, and finances may be relevant and ultimately impact management options considered and selected.
Time Redefined
Time has been redefined under the new E&M framework to include non-face-to-face time spent in the management of the patient. In lieu of complexity of MDM, the total time spent by the rendering practitioner on the date of the face-to-face encounter can be aggregated to determine the outpatient or office E&M service level. Previously time was narrowly defined; but now includes the following non-face-to-face activities when performed for the purposes of assessing and managing the patient on the date of the visit:
Preparing to see the patient (e.g., review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
Care coordination (not separately reported)
In addition to recording the precise total time on the date of the face-to-face encounter, providers should also document explicitly how that time was spent, including both face-to-face and non-face-to-face activities in the management of the patient. It is important to note that only physician time on the same date as the visit can be counted. We further caveat that time spent in services separately reported, such as interpretation of an EKG, be carved out of the total time aggregated toward the E&M service. Recently, the AMA underscored in clarifying guidance that the performance of other services reported separately should not be included in total time. They further stipulate that travel time should also be excluded.
A departure from previous requirements, counseling and coordination of care no longer need to dominate the visit for time to determine the level of service. Templated time attestations, indicating greater than 50% of the face-to-face time was spent counseling, are not necessary. Using outdated templates, providers may short-change themselves by capturing only the visit time rather than the total time spent in the management of the patient. Evaluating documentation templates for office progress notes is critical to ensure that providers can integrate free text, incorporating specific activities and how time was spent on the date of the face-to-face encounter.
CMS indicated in a recent Fact Sheet surrounding the 2021 Office/Outpatient E&M Services that reviewers will use medical record documentation to determine the medical necessity of the visit, as well as the accuracy of the time spent when time is relied upon to support the E&M level. In the Fact Sheet, they referenced specifically the review of start/stop time or documentation of total time. [4]
SunStone Consulting offers comprehensive services geared to help hospitals, health systems, and physicians evaluate and navigate the ever-changing regulatory environment. If you have any questions, please contact: Vonda Moon, Joli Fitzgibbons, or Cathy Archuleta.