The Proposed 2021 Medicare Physician Fee Schedule changes to office/outpatient evaluation and management (“E&M”) visits that if finalized will become effective January 1, 2021. While the documentation change for Practitioners is a welcome change, the timing poses a challenge to Practitioners already overburdened due to the COVID-19 pandemic.
The anticipated changes for office/outpatient E&M visits will allow practitioners to choose the applicable E&M visit level 99202-99215 based on either:
The new, American Medical Association (“AMA”) modified Medical Decision Making (“MDM”) table, along with medically appropriate history and exam, or;
Total time personally spent by the practitioner on the day of the visit, including face-to-face and non-face-to-face time.
While the documentation requirements surrounding history and physical exam have been relaxed, we have found the new requirements present the following challenges and potential risks:
Practitioners who work in both the outpatient and inpatient environments will be required to follow two different sets of guidelines for assigning the E&M levels. Adhering to separate guidelines for different settings could create confusion for coders and Providers alike.
The new MDM table is more focused on management of the patient’s condition, with an emphasis on the Practitioner’s cognitive efforts. Therefore, a comprehensive understanding of the new MDM scoring methodology is necessary to capture all relevant detail within the assessment and plan. Documentation pertaining to communication with other health care providers, obtaining information from an independent historian, review of medical records, ordering and interpretation of tests are among documentation elements potentially impacting the level of MDM.
Current electronic health record (“EHR”) templates may impede these efforts:
Outpatient visit templates previously structured on current guidance; history, physical exam and review of systems may not effectively capture the modified MDM guidelines.
Inability to capture the face-to-face and non-face-to-face time for the time based methodology.
SunStone has been studying the modified MDM table and has found providers need to be attentive to E&M visit level 4 scenarios as the application of new guidelines for outpatient progress notes do not necessarily yield the same level of service providers may be selecting under existing E&M guidelines. In auditing visit levels utilizing the new versus existing E&M guidelines, we have found that Practitioners would benefit from either changes to the EHR template and/or focused education.
Due to the potential impact on revenue and/or compliance, we encourage Providers develop and/or reevaluate their implementation plan as follows:
Conduct an E&M level assignment audit utilizing the current methodology versus the 2021 MDM table to identify potential differences in levels that could pose risk and/or reduce reimbursement;
Create separate inpatient and outpatient templates for Providers rendering care in both settings;
Update progress note templates, to include capture of all data elements reviewed and analyzed as outlined in the new MDM table, as well as both face-to-face and non-face-to-face time spent by the Practitioner on the day of the encounter;
Conduct a documentation and coding workflow review to evaluate changes necessary based on the relaxation of documentation requirements;
Facilitate education for coders and Practitioners surrounding:
Scoring utilizing the new MDM table; and
Time elements which contribute toward total aggregated time to include:
Reviewing and ordering tests and medications;
Obtaining history;
Examining the patient;
Documenting clinical information in the health record;
Counseling, communicating and coordinating care with other providers.
SunStone offers services specifically geared to helping Practitioners navigate the upcoming changes. If you have any questions, or would like assistance evaluating your overall preparedness please contact any of our team listed below:
Vonda Moon, Joli Fitzgibbons, Danielle Wyld, or Cathy Archuleta