Boots on the Ground – E/M 2021 Implementation

By working together with the physicians and some key staff members we were able to educate the practice in appropriate coding principles and they now recognize what's important to document. These providers also told me that the task of documenting visits, which had been so tedious, is really much quicker now that they know what's important to support the coding level.

For example, current guidelines require a clinically appropriate history and exam. This relieves the pressure to obtain either a complete history or perform a comprehensive exam simply to support their level of medical decision making. And this particular practice which I've been working with since the beginning of the changes has told me they're actually starting to see more available scheduling time in their day. This should also lead to increased revenue opportunities.
LM:Increased revenue opportunities should be welcomed news to providers. What are you seeing are the biggest pitfalls that you've seen in your work or that providers have shared with you?
NC:One of the biggest concerns is choosing between the two methods of documenting medical records. Providers can now select either medical decision making or time to support the E&M level. There's another practice I worked with that wanted specific guidance on whether it would be better for them to utilize MDM, medical decision making, or time guidelines. We performed coding and documentation reviews on their current medical record and as a result we were able to work with each provider to identify which methodology better suited their visits and their documentation styles.

Another issue for many practices is knowing that they need to document differently for hospital visits and office visits. We had discussed in another podcast about the high error rate using previous guidelines and we're still using these guidelines for hospital and other E&M places of service. One physician group brought me in to do a review of their hospital coding since the providers had previously been audited, but they had not yet educated their providers or staff. A coding review showed that they were still selecting incorrect codes and exposing themselves to an even further risk of audit. After we customized and delivered education to the providers and also created some practice specific templates, they're now documenting more compliantly and their risk of revenue loss has decreased.

One other concern is with EHRs. As we mentioned with the specialty practice earlier, providers should ensure that their electronic health record documentation templates are updated to both revalue medical decision making and deemphasize history and exam in the E&M level calculation. They should also ensure that the time related to each code has been updated to reflect the new increased ranges.

LM:So what went right for these providers then Nancy?

NC:I'm definitely seeing that providers who are taking proactive steps by reviewing their documentation and educating themselves in their staff are feeling more confident in their documentation and coding. Some have even shared that they're breathing a sigh of relief and actually going back to the business of practicing medicine again. Through all of our work together we've helped them to link their clinical intuition with documentation requirements.
LM:Thank you for your insights Nancy. Be sure to watch for the next podcast in the series that looks at what's in store for future coding changes.

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