Changes to coding and documentation guidelines for E/M office visits, which account for almost $23 billion in Medicare spending, aim to simplify the process for providers. Effective Jan. 1, 2021, some changes of the overhaul include eliminating history and physical exam as determinants of a visit’s code level; letting physicians choose if their documentation is based on medical decision-making or total time; and modifying medical decision-making criteria to shift from adding up tasks to focusing on what tasks affect the management of a patient’s condition.
The AMA included 10 points on its checklist. They are below:
- Identify a project lead
- Schedule team preparation time
- Update practice protocols
- Consider coding support
- Be aware of medical malpractice liability
- Guard against fraud and abuse law infractions
- Update your compliance plan
- Check with your EHR vendor
- Assess financial impact
- Understand additional employer or payer or medical liability coverage requirements
More information on the changes can be found here.
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