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Providers Need to Know E&M Code Documentation Changes

April 4, 2019

E&M Codes DocumentationPhysicians have been trying for years to persuade the CMS to revise evaluation and management (E&M) documentation requirements as being excessively burdensome, especially for those primary care providers treating very sick patients. CMS has finally listened, and with input from the AMA and more than 170 other patient and physician advocacy groups, developed a list of proposals some of which were welcomed as needed changes while some others were opposed by physicians and patient advocacy groups.

Because the proposed fee schedule runs close to 2,400 pages, here is a (very abbreviated) update of what’s happening so far, and what providers might expect in the coming months, with many office visit changes going into effect in 2021.

Goodbye to repetitive and unnecessary documentation

Previously, physicians needed to re-document elements of medical history and physical exam in the patient’s visit. The new changes will focus instead on the patient’s medical history since the last office visit.

Additionally, information recorded by staff or the patient that needed to be re-documented by the physician is no longer required. Also gone is the need to document the medical necessity of a home visit instead of an office visit. 

The immediate effects will be more time for physicians to spend in patient encounters as well as more rapid access to relevant patient information in their records. CMS calculated that once implemented, the proposed changes could reduce the time spent on documentation tasks by 1.6 minutes per visit. This would add up to 51.2 hours of total time saved annually for a provider seeing eight Medicare patients a day.

The forces behind the changes

The AMA-convened study group is also working to make recommendations to CMS that better reflect the real needs of both patients and providers.

In a February 2019 meeting, the AMA CPT Editorial Panel approved revised guidelines for both established and new office visits. Revisions included, among other changes, guidelines for office or outpatient visit codes of 99202-99215 eliminating history and exams as key components in choosing the appropriate service level.  

No collapsing of payment rates before 2021

One of the committee’s actions was sending a letter to the CMS administrator advising against implementing the proposal of “collapsing” coding payment rates for four separate office visit services into a single combined rate. Objections were voiced by physicians over the possibility that it could result in unintended harm to specialties treating the sickest patients as well as those under care of comprehensive primary care providers.

CMS announced postponing of the E&M coding collapse for at least two years to have time to work together to build consensus on modernizing office and outpatient E&M coding as they continue to analyze those issues and plans for offering solutions to go to CMS for implementation in the near future. As the CMS noted in the Final Rule:
“We are finalizing a significant reduction in current payment variation in office/ outpatient E&M visit levels by paying a single rate for visits at levels 2, 3 and 4 (one for established and another for new patients.) However, we are not finalizing inclusion of level 5 visits in the single rate in order to better account for the care and needs of particularly complex patients.

 E&M reporting guidelines have been restructured into three sections:

  • Guidelines Common to all E&M services
  • Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home, Custodial Care, and Home E&M Services
  • Guidelines for Office or Other Outpatient E&M Services, to distinguish new reporting guidelines for Office or Other Outpatient Services coded 99202 through 99215.

Other revisions in the CMS proposed E&M changes:

  • The CMS decided to not implement its previous proposal of cuts to halve reimbursement rates for office visits on the same day as other procedural services furnished by either the same provider or another physician from the same practice.
  • A proposal to create a new indirect practice expense category for office visits has also been dropped. This would have resulted in major payment changes for a number of specialties and treatments, including a more than 10 percent cut for chemotherapy services.
  • The code 99201 for “level one new outpatient visit” has been deleted.

Additional revisions affecting codes 99202-99215:

(Note that both history and exam are required; however they will not be scored.) Revisions to some MDM elements associated with the above visit codes as follows:

  • “Number of Diagnoses or Management Options” has been changed to “Number and Complexity of Problems Addressed.”
  • “Amount and/or Complexity of Data to be Reviewed” was changed to “Amount and/or Complexity of Data to be Reviewed and Analyzed.”
  • “Risk of Complications and/or Morbidity or Mortality” was also changed to “Risk of Complications and/or Morbidity or Mortality of Patient Management.”
  • Revisions to codes for prolonged patient services, with or without patient contact, have been approved along with definitions of time for visits linked with 99202-99215 from “typical face-to-face time” to “total time spent on the day of encounter.”

Work with a medical billing service to reduce confusion in E&M billing

The revised E&M guidelines, while a welcome relief to many providers, can also create some billing headaches for your back office. Your practice doesn’t have to wade through the new revisions alone: M-Scribe has been helping practices of all sizes and specialties with their billing, coding and practice management requirements since 2002.

With the ability to work with all medical billing software, your claims are checked for proper codes, for regulatory compliance, dollar totals and confirming payer accuracy before submission, resulting in higher rates of reimbursement and a boost in your revenue cycle. Our experienced staff of coders and other medical claims personnel are continually kept updated on the latest payer guidelines, with a tracking system that reduces the chance of lost claims and missed payments.

Contact us at 770-666-0470 or by email to learn more about how you can increase revenue while ensuring full compliance with all federal, state and industry regulations.


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