October 16, 2020 | By Scott Kraft, CPMA, CPC
It’s fair to say the 2021 changes to the E/M documentation guidelines ease the documentation burden on the rendering provider for certain aspects of the note. These welcome changes give more heft to the clinical relevance of the patient’s case and the provider’s treatment, rather than the legacy documentation guidelines’ focus on counting certain elements of history and examination.
But nobody expects payers to stop auditing these claims, and recoupment efforts are likely to continue – or even increase based on how the guidelines are interpreted.
While it is commonly believed the new guidelines are “easier” for the provider, don’t let that description be interpreted to allow for lax note documentation. One thing that hasn’t changed – medical necessity is still the overarching criterion on which payment for services is based.
Here are some key areas to focus on when training your providers ahead of the 2021 changes:
- Freshly documented history and exam for clinically relevant areas for the patient. With more latitude to carry forward elements of the history and exam, if it becomes habit-forming, the history and exam will end up becoming stale and full of contradictions. As these rules no longer require specific volume of bulleted aspects of history and exam, providers should focus on a clear explanation of the patient’s condition in the history and an examination of clinically relevant areas at each encounter. Areas that aren’t pertinent to the visit don’t need to be documented anyway.
- Don’t become over-reliant on time. Documentation of time spent on a visit no longer requires documenting that more than half of the face-time was devoted to counseling and/or coordination of care. But the time described in the note still must reflect actual face-to-face time and still must make sense in the setting of the services rendered. Nobody believes a young, otherwise healthy patient with a recurrence of seasonal allergies would warrant a 45-minute encounter. It’s more important than ever that the medical thought and decision making process be captured when time is being used to support the service.
- Show your work. Often not memorialized in documentation of patient encounters are certain tasks that are inherent to the service, such as discussing the patient with other providers, reviewing old records or the ordering and review of certain tests. The 2021 documentation guidelines place more weight on documentation of the order or review of each type of test result, as well as the discussions and engagements outside of the room that help inform patient treatment. Rather than focusing on the same review of 12 systems every time the patient visits, a focus on these areas could ensure that higher-level codes are supported for medical necessity on a more consistent basis.