Rewriting the Physician Office Visit Note: Ensuring Compliance in Medical Documentation in 2021

Are you prepared for the sweeping changes made to the “traditional” 1995 and 1997 evaluation and management (E/M) guidelines for office and outpatient visit codes you have been accustomed to for two decades?

All CPT changes take effect on January 1, 2021. For E/M, these changes include both definition and guideline revisions aimed to assist our providers in focusing instead on quality patient care, and lowering their stress levels and burn out mentality. The ‘Patients over Paperwork’ initiative developed by the Centers for Medicare and Medicaid Services (CMS) aims to decrease administrative tasks placed on providers and high volumes of note bloat due to voluminous bullet point checks and outdated requirements to remember.

Changes

The E/M major changes include eliminating:

1. CPT code 99201 for a new patient; and

2. Using patient history and physical exam as a criteria for code selection

It is imperative to understand that providers should still be capturing relevant and pertinent patient history and physical exam elements assisting in medical decision-making. These elements support the overarching medical necessity that is the driving factor in all medical services and encounters.

In addition, the E/M major changes encompass:

3. Medical Decision-Making (MDM) must meet two out of three elements; or

4. Total time for each encounter will drive code levels; and

5. Both new and established patients are scored the same if using MDM

Medical Decision-Making

CPT provides a useful Table for CPT E/M Office Revisions for Level of MDM, effective January 1, 2021. Please see it here: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

There are three elements that make up MDM in 2021:

A. The number and/or complexity of problems addressed

B. The amount of data and/or the complexity of data to be reviewed and analyzed

C. The risk of complications and/or the morbidity or mortality of patient management

The levels of MDM are the same in name from current guidelines. These levels will still be Straightforward, Low, Moderate, and High in 2021. Therefore, with the focus of E/M major changes solely on CPT codes 99202-99215 for both new and established patients in the office or outpatient setting only, 2021 identifies:

Straightforward MDM as equivalent to 99202 or 99212;
Low MDM as equivalent to 99203 or 99213;
Moderate MDM as equivalent to 99204 or 99214; and
High MDM as equivalent to 99205 or 99215

The MDM Table includes categorical criteria that must be met to qualify for a code level, but providers will now be able to document only the diagnosis addressed at the date of service under the number and complexity of problems addressed column. Providers will also drastically reduce note bloat under the amount or complexity of data to be reviewed and analyzed column because they are no longer including repetitive test data not pertinent or clinically relevant to the encounter. They will also get credits for the necessary tests ordered and reviewed independently, or if another physician’s test interpretation and opinion on patient management is necessary. Physicians will also finally be able to detail care plans to include social determinants of health that affect their medical decision-making under the risks of complications or morbidity of patient management column.

Time

Time has changed as well for office and outpatient E/M services in 2021. Our current guidelines are all about face-to-face time and activities spent with the patient, but new 2021 changes include non-face-to-face work as well on the date of service. The most important consideration in 2021 is capturing both elements of time, the total time, in the medical documentation.

The AMA has given us examples when providers should be documenting time:

Reviewing tests in preparation for a patient’s visit
Counseling or educating a patient, family or caregiver
Reporting test results to a patient by phone
Ordering medications, tests or procedures
Documentation work performed at home

Further, 2021 provides time thresholds that must be met if providers want code levels based on time.

For new patient visits:

99202 must be for 15-29 minutes of total time spent on the date of the encounter
99203 must be for 30-44 minutes of total time spent on the date of the encounter
99204 must be for 45-59 minutes of total time spent on the date of the encounter
99205 must be for 60-74 minutes of total time spent on the date of the encounter

And for established patient visits:

99212 must be for 10-19 minutes of total time spent on the date of the encounter
99213 must be for 20-29 minutes of total time spent on the date of the encounter
99214 must be for 30-39 minutes of total time spent on the date of the encounter
99215 must be for 40-54 minutes of total time spent on the date of the encounter

Documentation Compliance

The 2021 changes in office and outpatient E/M definitions and guidelines provides an opportunity for providers to meet documentation compliance standards from the start and not fall prey to revenue loss and post-payment audits.

With four weeks left before these 2021 changes take effect, here are some actionable items providers can take away:

Deploy education on 2021 office and outpatient E/M coding changes to your providers and coding and billing team
Conduct post-education implementation with practice/dummy coding and documentation
Find a coding compliance champion to spearhead the 2021 changes
Contact all your payors – are they implementing these 2021 changes?
Review and update EMR templates for compliance with new MDM and time changes (for office and outpatient E/M only)
Understand and identify whether MDM or time is more favorable for encounter type(s)
Update your practice’s compliance program to align with 2021 changes
Document, document, document
Remain honest to the patient, the encounter, the MDM and the time
Ensure medical necessity is overarching the service

And as a final important reminder to keep on the back burner, under the program rule on Interoperability, Information Blocking and ONC Health IT Certification, which implements the 21st Century Cures Act, patients will soon have access to their medical records starting April 5, 2021. Physicians will have to rewrite their office and outpatient notes with also their patients in mind. This means cleaning things up for readability – avoiding and eliminating confusing medical jargon and abbreviations that can easily be misinterpreted by patients.

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Photo courtesy of: Lexology

Originally Published On: Lexology

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