February 24, 2023 | By Sonal Patel, CPMA, CPC, CMC, ICDCM
Well, the time is finally here! 2023 has ushered in a new standard for how we look at evaluation and management (“E/M”) services. Physicians, providers, coders, auditors, educators, and compliance professionals alike are finally able to utilize much more than the “bean-counting” methods set forth by the Centers for Medicare and Medicaid Services’ (“CMS”) 1995 and 1997 (“95” and “97”) E/M guidelines. At last, the work performed by our medical doctors and healthcare providers can be better captured and rewarded through their critical thinking and medical decision-making, or their valuable time spent in serving their patients.
But how do we get our physicians and providers to capture all that higher-level thinking in the electronic health record (“EHR”) or electronic medical record (“EMR”)? For years now, these electronic systems have dissuaded many healthcare practitioners from “writing” all their considerations and thoughts on their patients’ disease status, management, and treatment. Instead, these electronic methods prompted medical professionals to simply apply check marks in an endless list of boxes for “convenience”. I daresay this “convenience” is what has led to the incredulous volume of post-payment audits of 95 and 97 E/M services over the past decade. For example, in much of the audit work I have performed, there has been consistent overutilization of check marks for every organ system examined when not medically necessary for the problem addressed. Moreover, there has been a plethora of copy and pasted, or carried-forward documentation irrelevant to the day’s service based on the construction of the various EHRs and EMRs currently in use in medical practices and health systems.
To help answer the question I posed above, I believe it is important to guide our practitioners to remember all the ways they now have available to fully paint the patient’s medical picture at every unique encounter. The American Medical Association (“AMA”) has worked tirelessly with the help of CMS to reduce the clinical documentation burden and note bloat that has consumed the profession for years. Instead, new guidance in our Current Procedural Terminology Manual (“CPT®”) provides coding definitions and guidelines that instruct you to include a medically appropriate history and physical examination. So, no more! Bye-bye! Gone are the days of each body area being examined and “bean-counted” for the mere finger splinter that the patient was evaluated and treated for on an exact date of service.
To that end, it is imperative that practices and organizations get their EHR and EMR vendors involved as soon as possible! Work with your vendors to find better ways to utilize the electronic systems to capture the demands of today, as well as alleviate the note bloat functionality that these entities contributed to for years. Remember, in 2023 and beyond, it is simply unnecessary to continue utilizing templates that consist of the large chunk of History (i.e., history of present illness; review of systems; and past family social history) and Exam (i.e., every single organ system and every single body area) elements.
Requirements today are intended to help you avoid note bloat! Additionally, this new E/M standard can prevent the erroneous applications of carried-forward and copy and pasted documentation within EHR and EMR systems; when instead, the practitioner can be redirected to create an encounter note based on the current encounter with the patient. In my opinion, both note bloat and documentation template compliance risks can be thwarted with the new E/M standard.
Another important factor of the new E/M standard involves the inclusion of the physician or provider’s consideration of treatment or additional testing to the patient’s overall risk of complications, or morbidity, or even death. In my opinion, this is a huge inclusion to the CPT® guidelines for E/M services! I say this because I have seen outstanding pre-operative procedure documentation over the years that explicitly details the surgeon’s thought process –
- why s/he should wait and see – because the patient has high cardiac risk; or
- why s/he should cut immediately – because the patient’s appendix burst; or
- why s/he must advise of great risks to life – because the 4mm carotid body tumor is proving partial paralysis to patient
This new E/M standard allows medical practitioners of all specialties to begin qualifying and/or quantifying for that greater level of risk (moderate or high) in their patient populations when it comes to testing and treatment considerations. Of course, this new E/M standard also considers the more commonly understood risks that apply because the testing and treatment are definite green-light decisions that inherently pose risk to the patient’s life. I further believe this new E/M standard far exceeds the 95 and 97 notion of risk that stopped well short, at merely managing the patient.
These are just a few of the elements in the new E/M standard for 2023 and beyond that impress me. I am looking forward to treating the sunrise over 2023 as a fresh start for all of us. I believe our physicians and providers have always thought this way – with medical decision-making playing the starring, pivotal role in how they make calculated considerations in addition to evaluating the risks of tenable complications in their treatment decisions. In my opinion, it continues to be a matter of ensuring all this critical thinking is captured within the patient medical record, as well as eliminating the risks that modern tools, like the EHRs and EMRs, have placed on our healthcare practitioners. When partnering with our physicians and providers, this dawning of a new era affords an opportunity for coding compliance education to be deemed as preventive care for the business of medicine.
CPT® 2023 Professional Edition, pages 4-12.
Your next steps:
- Register to attend the NAMAS 2023 Virtual Conference to learn more.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!