As we begin the new year and our focused training for the 2023 E&M changes and revisions, I’d like to encourage everyone to refocus their efforts on column three of medical decision-making.
The header of column three is very specific, and it’s wordy. I think sometimes we fail to notice that because we’re stuck in the way we used to look at this column with 95 and 97 documentation guidelines. MDM favors the table of risk that we had with 95 and 97 documentation guidelines, and column three favors column three in the table of risk, which was then patient management. The title of column three does include the terms “patient management.” However, what it really says is the Risk of Complications and/or Morbidity or Mortality of Patient Management. Remember, in column three with 2021 documentation guidelines, that we are including the risk of complications, not just patient management.
We should be reminding providers that when they are documenting the patient management, they are not only documenting patient management. Most of the documentation that we’ve seen so far utilizing 2021 documentation guidelines has continued to rely on documentation of merely managing the patient as opposed to the risks of managing that patient. How do we document for this shift? Well, AMA has asked, “has the patient reached their treatment goals”? We’ve picked up on that one. AMA has also said we can write the considerations of other treatment. We’ve seen some of that. The “probables”, the rule outs…we’ve had some documentation of that, but all the other risks -the risks that our provider is taking on, the thought process, the entire risk of everything about that patient and what’s going on should also be reflected in the documentation.
We can go back to the example of a patient who is receiving an antibiotic or a steroid injection and has an underlying comorbidity that must be taken into consideration prior to giving them that new medication. They must consider the status of that comorbidity first. That type of risk of managing the patient is absolutely what the AMA is ensuring that providers are counting in that risk, but our providers must document it. That is part of the risk of patient management, and that’s what we’re really missing in the documentation and that’s definitely what is missing when we have copied and pasted assessment and plans and when we have minimal documentation and assessment and plans.
We need to help our providers understand, regardless of type or place of service — inpatient, ED, or clinic setting, when documenting assessment and plan, we really need to understand the risk of managing that patient. Even if they are consulting that patient to another service, they are responsible for managing that patient until they’re picked up by that other service. That risk should be documented in the chart.
If you have any questions about this, please feel free to drop me a line, and I’ll do my best to help you, but explore this, help your providers understand and then see where this can go for documenting and what it means. That’s why they’ve removed some of these examples and then again reminded us that these are only examples, and they are examples of treatment and not examples of risk. So, consider this amongst your auditing and coding team and then again have some provider meetings about what this means for your specialties’ documentation. I hope this is helpful for you. I also have a video on this topic on the NAMAS YouTube channel here. I hope you’ll contact me if you have any questions or needs within your organization.
Your next steps:
- Contact NAMAS for information about customized staff and provider training.
- 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!
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