January 27, 2023 | By Stephanie Allard, CPC, CEMA, RHIT
A large part of the last 6 months for auditors and educators has been spent in preparation for the new 2023 revisions to the 2021 E/M guidelines. For some of the patient settings, this is a large change. While many see the 2021 E/M guidelines as an easier process due to no longer scoring the history and exam, we know that the change to the Medical Decision Making (MDM) grid now will require some encounter information to be documented and applied differently. Now that 2023 is officially here and the 2021 E/M guidelines are effective in the various patient settings, what should we be focusing on?
In the past when we were preparing for the 2021 E/M guideline initial implementation, I had found that not every provider retained the training information from the education sessions that were held too far in advance of the effective date of large changes. The end of the year tends to be busy for everyone between finishing out business for the year and the holiday breaks. It is going to be important to evaluate what you as an auditor/educator have done to prepare vs. the information that you have sent out to your providers to get them ready for the change. Whether your providers have already completed or started their training, it would be a great idea to send out a reminder that we started utilizing the 2021 guidelines as of Sunday January 1, 2023. You could include a compact bullet point list reminder with a high-level overview and an additional focus on the areas that they need to be most aware of. This will also remind the providers that you are there as a resource if they have any questions.
We also need to consider the providers who see patients primarily in the outpatient clinic setting and at times conduct consults in the hospital. While they should already be familiar with the 2021 E/M guidelines, the scenarios that they will experience in the hospital settings will be different. For example, can a surgeon receive credit for reviewing each of the tests that an Emergency Department physician ordered?
Reviewing the current templates and macro statements will be an important part of compliance going forward. When we think about time-based billing for example, we need to ensure that the providers are aware that it is not just a matter of stating “I have spent 60 minutes today”, but instead that they have a compliant time statement that they are updating appropriately for the individual patients. After the initial implementation of the 2021 E/M guidelines, I would often find in my audits that providers made no changes to their templates and macro statements or documentation style. While the process remained more administratively burdensome, it also was the root of some of the audit variances.
Ultimately, the audit plan for your organization needs to be considered. One of the only ways that we will know if the training information was retained and understood will be to look at the documentation to evaluate the changes the providers made in their templates/macros, and to see how they are applying the new set of guidelines. When creating an audit plan with the 2023 revisions in mind, you can think through areas that we have anticipated to be a difficult transition. For example, Data the 2nd element of MDM in the hospital setting can incorrectly drive up a level of E/M service if the provider does not understand the rules surrounding Reviewing vs. Ordering of each unique test. If your audit plan would leave some providers in a place where they do not get feedback for many months, consider implementing a smaller project – either internally or with the help of outside auditors – to review a smaller sample of areas that are potentially a compliance risk.
Remember that even though the guidelines are intense with multiple rules and definitions throughout, in our role as an auditor and educator we can be here to breakdown the complexities and help our providers focus on the areas that are most pertinent to them and direct them to where they should be implementing changes to their documentation and code selection.
Your next steps:
- Schedule a consultation for 2023 audit planning and a provider documentation review.
- 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!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
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