July 3, 2020 | By Stephanie Allard, CPC, CEMA, RHIT
As we move towards implementing the 2021 E/M changes, we need to evaluate areas of bad habits within E/M encounter documentation. I have noticed in my current reviews that many providers are in the habit of documenting the same exact amount of time repetitively and not always showing the specific time spent for each individual patient encounter. Has this pattern been seen already? Well, sure it definitely has, but how many auditors have let it pass by? Or how many times has it gone unnoticed based on the case-mix within the audit sample? We are moving towards changes that will allow providers to document and bill based on time without the requirement that counseling and coordination of care must dominate the encounter. This means that the documentation must reflect the true time spent by the provider on a given evaluation and management service on the encounter date.
I am also noticing providers that default to documenting the typical time of the E/M level that they are billing for, which causes multiple encounters to have the same exact time documented regardless of the patient’s stated severity and complexity of care. This style of documentation, and often the use of macro statements, does not show each patient encounter as being unique. For example, when a provider bills 99204 for the majority of their new patient evaluations and each patient has a statement that 45 minutes were spent in counseling and coordination of care, I begin to question the validity of the time statement, especially when the level of medical necessity supported varies from one encounter to the next.
When it comes to documentation guidelines, there is a lot to remember and we need to point out areas of concern as we see them. In the case of properly documenting time spent, the providers may feel that their use of a macro statement covers them for whichever E/M code level they would like to bill. If we allow our providers to continue to repetitively document the same exact amount of time for all patients, I think the associated compliance risk will become a major problem when it comes to supporting outpatient E/M services in 2021.