Evaluation and management coding changes: What organizations need to know

Colleen Goethals, vice president of mid-revenue cycle at Xtend, spoke with Melissa Caswell, director of coding audits and education at Xtend, about recent changes to E&M coding requirements and how organizations can set themselves up for success.

Four key insights were:

  1. E&M coding services account for a large portion of physician services and play a key role in financial health and compliance programs. Although those services are common across many types of healthcare organizations, E&M-related reimbursement is especially crucial for family practice and primary care providers. 
  1. The industry recently witnessed the first major overhaul to the E&M guidelines in 25 years. In 2021, the AMA and CMS implemented significant changes to E&M code selection requirements for physician office visits and outpatient services, which were extended across other E&M service earlier this year.

The changes eliminated requirements that were not essential to patient care, such as the need to document a certain level of history rather than relevant medical history. The goals of the revisions were to reduce administrative burden. "Patient care should be driven by the need to treat patients, not the need to satisfy a coding requirement," Ms. Caswell said.

  1. Documenting the decision-making thought process remains a challenge. Despite the changes, there are still requirements to document medically appropriate history, medical decision-making (MDM) and/or a physical exam. Documenting MDM in particular is a challenge for both physicians and coders/auditors because it can be subjective: it centers on being able to clearly represent and visualize what occurred during the patient's visit, what medical decisions were made and how those decisions were reached. 

To assist, the AMA has developed new MDM guidelines; however, they are a framework and not meant to be rigid. "Clinical judgment does play a role and that is where the provider documentation of patient-specific risk comes into play," Ms. Caswell said.

  1. Time is a patient-specific but objective metric for determining E&M coding. Defined as the total time on the date of the encounter spent by the provider performing qualifying activities, it includes both face-to-face and non-face-to-face time with the patient and/or caregiver. 

To support time-based E&M documentation, providers must specify the timespan of each clinical encounter. Yet, audits have found the same timespan being documented for each patient seen on a given day, which may be due to the way EHR systems are templated.

Ms. Caswell said that discovering oversights such as these proves the continuous need for auditing and education. "This allows organizations to take a proactive approach to mitigating compliance risk and lost revenue. There's nothing worse than being paid for a service and then having to refund the payment due to improper coding or billing."

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