By Shannon Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA®

AMA’s changes are complementary to the CMS proposed changes to this code set.

 The Centers for Medicare & Medicaid Services (CMS) is moving quickly on its strategies for outpatient office evaluation and management (E&M) services, targeted for implementation in 2021, and the American Medical Association (AMA) is working hard to try and keep up. Many who read the final rule for 2019 noted the E&M changes to be implemented in 2021 for the office/outpatient code set 99201-99215 and scoffed (myself included) that this would probably be much like ICD-10: an issue that gets kicked around a few years before final implementation.

Well, we (again, myself included) appear to be wrong, as AMA has released its own E&M coding rule changes, also to be introduced in 2021. The AMA is allowing comments for reconsideration until midnight Central Standard Time on Monday, March 25, 2019, and we once again encourage each of you to read the AMA publication and submit your feedback.

In a nutshell, the AMA’s changes are complementary to the CMS proposed changes to this code set, and they include:

  • Deletion of 99201
  • Removing history and exam as key components
  • New definitions for the medical decision-making (MDM) components
  • Modifying the definition of time-based services and what is included in time
  • New guidelines sections within E&M

Deletion of 99201

The AMA has made the decision, based on utilization, to delete 99201 at this time. This code is rarely reported and therefore no longer needed. This actually makes sense, as most often we would only be reporting this code for encounters with essentially little to no documentation components.

Based on the current coding framework, the differences between the documentation requirements for a 99201 and a 99202 are that the Level 2 requires one review of systems (ROS) and one more organ system on an exam. There are those rare notes for which a provider may fail to include any ROS, but this is not typically the norm for most providers, as new and initial E&M services are usually their best documentation efforts.

Removing History and Exam As Key Components

AMA is changing the overall level of service scoring process by no longer requiring history and exam to be counted as key components. The change would then reflect that the history and exam should be medically appropriate. And here is the gray area. We already have this as an argumentative point of preventive guidelines: what is medically appropriate? If you are thinking ahead, you already know how this will be scrutinized. What would be the minimum history and exam that would be needed to indicate that the requirement for services being “medically appropriate” was met? Well, before we as coders and auditors arm ourselves with those boxing gloves, let’s consider why this change is being made. As of 2019, CMS has advised us that all components of the history may be documented and/or completed by someone other than the reported provider, as long as the provider is updating, supplementing, or approving the recorded chief complaint (CC), history of present illness (HPI), ROS, and past, family, and/or social history (PFSH). Therefore, if the whole history is no longer considered to be provider-level work, then there would be no need to continue to make it a documentation requirement.

That leads us to the elimination of an exam as a key component. Many coders and auditors have raised concerns of exam documentation looking the same from patient to patient, and day to day. The provider’s typical response is “but if that is the exam I do and those are the findings each time, how would you like me to say it differently?” And that makes perfect sense.

However, I believe we could all substantiate that there are providers clicking on that normal electronic medical record- (EMR)-crafted exam template for insertion into the documentation even when, just maybe, not every single element was actually part of the encounter. Forgive me, I tell this story often, but it is too appropriate not to share, and probably a good reason to support the elimination of exam as a key component:

I know a family practice provider in Arkansas with whom I have a great rapport and can be frank and honest. He is a really good doctor and wonderful to his community, even treating patients that approach him in a grocery store! However, while on-site we were reviewing an encounter of an 8-year-old with a wart. He documented an eight-point body system exam on the patient, and when we reviewed the note together, due to our candor, I asked him very politely if he actually did an eight-point body system exam, or was that just part of the template he chose?

Yes, your hunch is right, he admitted: it was part of the template. I went on to explain to him that technically, he falsified a legal record, and what he had done could be construed as fraud, as he was indicating that he did work that he actually had not done. The crazy thing is that he recorded that information for no reason at all! He billed a 99213, and for that, he only needed two organ systems – and he had vitals, and of course, he looked at the wart. So in all reality, he didn’t even need the full exam.

In most cases, we have encouraged providers over the years to wear a documentation seatbelt, to the point that many over-document what they need – either as a seatbelt, or because they just don’t even know what should or shouldn’t be there. This has led to them using templates that often identify work that was not completed during the encounter. The exam has become one big template. Therefore, rather than the AMA or CMS challenging providers on the accuracy and/or validity of their exams, they have merely decided to make it “as appropriate,” as opposed to level-specific requirements.

We will need to educate our providers to understand that this is not the elimination of history and exam from the documentation. Rather, each encounter should still include a history and exam; there are just no longer any scoring requirements. An encounter with no history and exam would not only be a legal liability but may fail to demonstrate medical necessity for the E&M service and/or procedural and diagnostic services. Obviously, this leaves us only with medical decision-making (MDM) in the 2021 changes to define our level of service.

New Definitions for the MDM Components

There is much controversy regarding MDM, as documentation guidelines vary from Marshfield scoring – and Marshfield includes ambiguity and increases the gray-area considerations. For this reason, CMS has requested comments on consideration of modification to MDM, formal acceptance of Marshfield, or other considerations. We might consider the AMA’s proposed change as a beginning point of conversation to reach those end purposes. The AMA is proposing verbiage change to the three MDM elements, and they will change to the following:

  • Number and complexity of problems addressed: This provides more specification so that the provider cannot merely provide a laundry list of diagnoses. Rather, it seems that the provider would be expected to indicate each presenting problem and the identified treatment plan for each.
  • The amount and/or complexity of data to be reviewed and analyzed: The purpose of this section of MDM is to consider the complexity of work expressed in terms of mental and physical effort of the provider within the encounter. The revised statement provides instructional guidance to not only count information reviewed, but also information that was analyzed as well.
  • Risk of complications and/or morbidity or mortality of patient management: This one is quite interesting. The inclusion of patient management indicates that we may have the ability to extend these considerations not only to risks associated with today’s encounter but also to managing this patient’s disease process or the acuity of their condition.

I personally think we still have much more to consider as we approach an MDM-only world, but I do believe that AMA has created a starting point that more readily stirs the documentation review to medical necessity, as opposed to the points-counting process.

 Modifying the Definition Of Time-Based Services And What Is Included In Time

Under our current structure, a provider may only use time when counseling and coordination of care dominate the encounter, and they can only count their own time that is face to face. The 2021 time change essentially alleviates all of these hurdles. First, time may be used whenever the provider chooses, as they no longer have to include that counseling and coordinating care dominated within the encounter. Next, they will now get to include all time spent on that date of service. This seems to include all pre-service work, time spent reviewing documentation, and even documenting the encounter – but again, it is only for that same date of service. Therefore, if the provider reviews documentation obtained from another provider the day/night prior to the encounter, this time would not count. If the provider fails to document the encounter on the same date of service, they would then not be able to include their documentation time in consideration of their service. This change seems to be in the best interests of improving health record integrity. In addition, we would now also be able to include time when more than one individual performs a distinct part of the E&M service. This is a long-needed change. Actually, in the Documentation Guidelines, it states within the MDM section (under diagnosis considerations) that nursing time and patient education time show complexity of an encounter, but under the current framework these do not really substantiate reported/counted work. This change sounds like it may help to capture true work that is being done for each patient.

New Guidelines Sections within E&M

The last update to mention would be an expected guideline revision. The guidelines would be divided into three sections. One would be guidelines common to all E&M services, another section specific to outpatient/office services, and the last section to include all other services (such as inpatient, ED, observation, etc…).

Time for Change

As you know, we have moved from a paper chart to an electronic medical record, and through this transition, shortcuts, and efficiencies have been created for the task of provider documentation.

We are all actively engaged in creating efficiencies, but I believe most would agree that this has led to documentation that does not always clearly identify the complexities of patient care, often leaving the reader to question what was actually done during the encounter. Therefore, these same efficiencies have led to more aggressive audits, and providers now find themselves documenting to non-clinicians, as opposed to their peers in a clinical approach.

Change is hard, but maybe this is a needed and welcomed approach to a new era of healthcare that is centered on electronic capabilities. We should start training and preparing now. How? Neither CMS nor AMA has addressed medical necessity – the overarching determining factor – so it seems, as we discussed, this will not be revised or deleted.

We need to help our providers work within the current framework now to demonstrate medical necessity to prepare them for this continued requirement in the face of so many coming changes.