On August 24, 2022 NAMAS hosted a FREE 90 minute webinar on
the 2023 revision for the 2021 Documentation Guidelines

This training was presented in a 90 minute session and hosted by:

Speaker: Shannon DeConda, CPC, CPC-I, CEMC, CPMA, CEMA

OnDemand access to this training is available, however CEUs are NOT provided.

Free Resources

MDM Chart by AMA – FREE Download        
2021 AMA Guidelines – FREE Download     
AMA 2021 E&M Technical Corrections        
AMA 2023 E&M Changes                              
2021 E&M Office/Outpatient Pocket Card   

Training Prep: Step-by-Step

Step 1:

Identify what providers are in need of training, and then what training each category will need.

Here we will start with 2 categories first:

  • Individuals who provide office/clinic service who have received 2021 DG training, but provide services in areas impacted by 2023 changes and therefore require additional training.
  • Individuals who have NOT received 2021 DG training, and who ONLY provide services in areas impacted by 2023 changes and require initial training.

Providers who have been documenting with the 2021 DG and actively receiving audits and feedback since the implementation should be able to attend expedited training sessions as opposed to those who are completely new to the guidelines.

Of course dividing these into further subsets would best benefit training by having “like” provider subsets attend training together such as hospitalists in one session, while ED providers have their own training session.

Step 2:

Consider your training dates.

Could CPT changes come at a worse time of the year? With major changes, effective January 1st, the struggle is the timing of the training. If the training starts in October and the beginning of November, providers could “forget” come January when there has been no hands-on use of the knowledge obtained. On the flip side, if you train in November/December, around the holiday scheduling, with the sheer energy and chaos of the holiday season, not to mention the patient load, providers retaining the knowledge is yet another concern.

What is the best solution?

There is no penalty for starting the year utilizing existing documentation guidelines- so it may be most advantageous to start the year off using the existing guidelines and then launch a robust initiative of training and implementation Q1.

Step 3:

Delay of full implementation does not mean you have to fully delay ALL training now. In the months that are leading up to January 1, consider taking existing notes and providing detailed audit notes utilizing 2021 Documentation Guidelines for review. Using a single note bi-weekly can generate conversation and begin to familiarize your providers with some of the changes to assist in the training process. In addition, this approach could help guide conversations on template modification and documentation adaption appropriate for January 1, 2023.

Step 4:

Feedback

No review (ie., audit) is complete without feedback and education on any noted changes, why the changes were needed, and efficient strategies to implement for documentation improvement while maintaining patient care as the focus of each encounter. 65% of the population are visual learners and by nature many providers are analytical thinkers. Therefore, a combination of the two should lead to an effective educational approach.

  • Of the records review, pull 2-3 samples and be sure include examples of both incorrect and correct leveling of the E&M service.
  • Handwrite on these HIPAA compliant records direct feedback by encouraging additional elaboration with key points and noting streamlining in areas in which over documentation of the required components were noted.
  • Be clear and confident in your findings and keep reminding the provider that the patient should look as sick or as stable as they appeared at the time of the encounter.

Step 5:

Continue the review cycle and integrate 2021 changes

Every 6-8 weeks continue to provide spot reviews on the providers who need additional training for better compliance. Using a HIPAA compliant office-based encounter, audit one of the notes using the 2020 documentation requirements and medical necessity guidelines. Now, take the same encounter and using 2021 rules audit the same note for a cross-comparison of the new guidelines.

Additional Resources

Provider Specific Training Events           
2021 E&M Audit Tool                                
Register For An E&M Webinar                 
View Team Bios                                        
E&M Video Resources