November 20, 2020 | By Brenda Edwards, CPC, CDEO, CPB, CPC-I, CEMC, CRC, CMRS, CMCS
The days of 2020 are winding down and I don’t know that any of us are going to be sad to see it go. While saying goodbye to 2020 and hello to 2021, we also say hello to the Evaluation and Management Guideline changes to 99201 – 99215. NAMAS has offered webinars throughout the year so we will be ready for this monumental change. We have learned about the code that will be deleted, changes in time-based coding, in-depth discussions on number and complexity of problems addressed, amount and/or complexity of data to be reviewed, risk of complications, and now we are going to look at documentation and how the medical decision making is scored under today’s guidelines compared to 2021. While we are looking at the documentation, consider not only what you find in the assessment and plan, but also the information that will assist in supporting the service that may be found in the history and/or exam. We need to ensure that our providers do not document less since only medical decision making will be counted.
I like to compare each encounter to a book. A good book needs:
- A title that is descriptive in what we are going to read. Compare a title of “Follow-Up” to “Hypertension Follow-Up.” The second title tells us more about what to expect than the first.
- An introduction and background for our story which is what we find in the history and examination.
- We also need the story to have a conclusion which is why the assessment and plan are important. We need details of what is going to occur beyond “follow up in one year” or “continue medications”. We need to know graphic buzzwords, such as “chronic”, “elevated”, “improving” and other words that help to set the severity of the condition(s).
So are you wondering why I’m talking about history, examination AND medical decision making, when on 1/1/21 we will no longer use the first two to determine the overall level of service, when we will only “need” medical decision making? It’s because the history and examination can be full of rich details that will help to support the medical necessity of the visit. I have been encouraging providers not to alter their current documentation of history and examination. While they will not need to count how many bullets appear in the review of systems or how many examination elements are documented, they should still document anything relevant to the encounter. You may have heard of MEAT (monitor, evaluate, assess, treat) being tied to risk adjustment coding; it is also solid documentation advice. When a provider shows “MEAT” in their documentation that affect the patient’s condition(s), they are saying in essence “look at everything that went into my thought process to make the determination on how to care for this patient today.” I like to tell providers to “think in ink” which means that the thought process in their minds must be apparent in their documentation.
Use this last month of time before the beginning of 2021 to do side-by-side comparisons of documentation. Audit under today’s’ guidelines and then audit under next year’s guidelines. You may find differences, or you may find that visits do not change too much. But whatever you find, be sure to share feedback with your provider. Ask questions! Ask your provider when you are unsure if the risk of the condition is “low” or “moderate” because their perspective can assist you in understanding their mindset and thought process.
I’m excited for 2020 to end and equally excited to audit provider documentation without having to count all of those pesky little bullets. I am happy that I will no longer have to tell a provider “The documentation didn’t support 99204 because you missed an element of family history”. Instead, I get to tell them “Your documentation is great because I can see the medical necessity in your documentation that is full of great supporting detail.”
Make the most of this last bit of time to be prepared. Merry Christmas, happy New Year and a happy new audit!