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By Shannon O. Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA, CMPM, CPMN DoctorsManagement |
2021 E/M Changes: Documentation Change or a Scoring Change

Coding


2021 E/M Changes: Documentation Change or a Scoring Change

Date Posted: Thursday, March 12, 2020

 

Recently while doing a provider training event at a large health system, a provider asked, "What advice do you have for us regarding the 2021 E&M AMA CPT Changes to the office E&M codes?" My response was short, simple, and merely one sentence. "Just keep documenting the way you have been documenting these services for the past 25 years." I know this may make you pause and ponder, "But wait, these changes were provided to ease the documentation burden, but yet your advice is to stay the course?" Again, my resounding answer is yes, because the changes made impact the scoring process of the encounter, not the purpose of documentation.  

Below are the most significant changes in a nutshell.
  • History and exam will no longer be scored. Please note, this does not say providers can exclude history and exam, but rather it should be documented as medically appropriate. 
  • Scoring the documentation to assign a level of service will be based on time or MDM. We will no longer be required to "bean count" HPI, ROS, PFSH, or Exam, but rather focus on the new requirements of MDM only. AMA has redesigned the Marshfield Scoring Process with a new consolidated MDM table for this purpose.
  • Time scoring guidelines change. A provider can bill any visit on time that they choose as opposed to only those visits consumed with counseling and coordination of care. 

Noting these most significant changes, we see that scoring is the common denominator. There are a few other updates, such as AMA defining some of the gray areas that Marshfield Guidance created within the MDM. Again, noting these changes also impact the scoring process and have no impact on the fundamental purpose for documentation. So, the purpose of documentation and demonstrating complexity of each encounter has not changed-just the scoring of it. 

In 25 years, has the true purpose of documentation changed? Well, the answer would depend on who you asked, and quite frankly, if we cannot point to an answer in black and white published guidance, then there is a chance that the answer is an opinion or interpretation. Do we have published guidance that identifies the true purpose (not requirements) of documentation? The answer is yes, we do. It just gets passed over by so many of us, all the while it has been there for 25 years staring us in the face. 1995 & 1997 Documentation Guidelines (DG) include an introduction that answers two very important questions: What is Documentation and Why is it Important?

As we consider the 2021 changes to the documentation scoring process, we as coding professionals, audit reviewers, and provider educational experts, our resounding message to providers should be Don't change a thing! Because the purpose of documentation has not changed, but rather, your job as the coder and auditor has. 

Let's consider the answers the DG provided to the questions of the "what" and the "why" for documentation and compare them to the most significant changes for 2021: 

1. The ability of the physician and other healthcare professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her healthcare over time. Best summoned up by saying one of the purposes of documentation is to chronicle the patient's health history, telling the patient's specialty specific story about their presenting problem. Keep in mind that regardless of age, patients are not always the best and/or most forthright about their health history and therefore the medical record can help prevent and avert conflicts in patient care. 

2021 Impact: None. Each encounter will still be expected to chronical the patient's plan of care for each presenting problem for which the provider assumes care. 

2. Communication and continuity of care among physicians and other healthcare professionals involved in the patient's care. The inclusion of this information ensures that any other provider rendering care to the patient is well informed. Whether they are treating the same presenting problem or a different problem that could be impacted by other health issues or treatment plans associated with other problems. Documentation ensures each care plan from provider-to-provider can best align. 

2021 Impact: None. Patient care should be the number one consideration of each provider-patient interaction. 

3. Accurate and timely claims review and payment. This goes beyond the mere collection of documentation elements formerly included in history and exam and rather focuses on demonstrating the medical complexity associated with each patient encounter. This means that documentation of each encounter will still have an obligation to explain the why of each service rendered and the complexity of each patient encounter, as once again, this is the underlying reason for documenting the patient encounter. Why did the provider walk into the room to see the patient? Why were the diagnostic or procedural services indicated for this specific patient during this encounter? Documentation of complexity includes the provider identifying any factors that contribute to more work. According to CGS Medicare, medical necessity is expressed in terms of physical and/or mental effort as well as identifying conditions that may cause increased risk and complications to treating the presenting problem. This is already an epic problem in the healthcare documentation process, and we must ensure that the relaxing of documentation requirements does not lead to a further rise of encounters that do not demonstrate the medical appropriateness and reasonableness, not to mention necessity.

2021 Impact: None. Providers will still be expected to file claims timely and have documentation to support the services rendered. 

4. Appropriate utilization review and quality of care evaluations. A Utilization Review (UR) varies from a coding and documentation audit in that a UR is a clinical focused review standardly using at minimum nurse trained reviewers. The UR is evaluating clinical treatment based on medical reasonableness and clinical indications of care. In contrast, audits are more focused on the coding and documentation as the guidelines mandate focusing on component counting (i.e., HPI, ROS, PFSH, Exam, and MDM). Therefore, UR helps by focusing on the quality of care provided to patients, which again, is not impacted by the volume of documentation requirements met, but rather on quality of the documentation of each service provided to any given patient. 

2021 Impact: None. UR and the validation of quality care will not change as we move into 2021, and therefore becomes reason 4 for our providers to maintain their current documentation process.

5. Collection of data that may be useful for research and education. Many may read #5 and say, "I am not in an academic environment and therefore this has no relevance to my documentation," but that would be incorrect. Remember that one of the reasons we convert documentation into codes includes the advantages that numbers provide in consideration of data analytics. The codes we bill are the catalyst for the data of healthcare provided in the U.S. and beyond. Our CPT coding provides the footprint of the service performed while the ICD-10 codes reveal the problem for which the service was provided. This information can only be abstracted from a live event through a culmination of documentation, and most of the time, this documentation is best demonstrated beyond the mere documentation components listed in 1995 and 1997 Documentation Guidelines. Analyzing data as it relates to disease onset and comorbidity management impacts all healthcare consumers as it becomes a predictive modeling based on our physiological and geographic pointers. Researching disease, injuries, illness, and comorbidities empowers advances in improvements of quality and quantity of life and would certainly be hindered with the mere documentation of MDM or the amount of time spent being the only entries made for patient encounters. 

2021 Impact: None. We all recognize that healthcare is progressively advancing in technology and patient care/interactions. Documenting less information is counter-productive of advancement. 

The above has been our directive on the purpose of documentation for the past 25 years, and while the guidelines and level of service requirements may not have worked well, the purpose of documentation has. 

I think that what we can all agree on has changed over the past 25 years is twofold; the value of documentation which has increased the requirements of documentation. 

  • The value of documentation has dramatically shifted as we have seen carriers place higher emphasis and demand on what is documented. Carriers are not only wanting DG met, but also the thought process behind all decisions, therefore placing a higher value on documentation.  
  • Providers are trained that documentation should be their communication tool from provider to provider, so they find the level of documentation demanded by carriers and DG ridiculous; therefore, the result is they undervalue documentation. This has led to a transition of the value of documentation. Providers are disparaged by the burden of documentation, which has been the focus of documentation relaxation initiatives. 

Oftentimes, we jump to say that this didactic shift was the product of the use of EMR in healthcare, and while it may have fanned the flame, we were already there way before that. Prior to an electronic template, we had a paper template that prompted a provider to do merely more than check yes/no, WNL (within normal limits), or an abnormal finding. Personally, since my initial exposure into the world of E&M documentation (nearly 25 years ago), the focus was on counting the components and adding them together to find the score for each patient encounter. Then we would identify the counted findings in that famous "up-code/down-code report," which would lead to our plea to providers to always document 4 HPI, 10 ROS, 3 PFSH, and 8 organ systems on the exam to ensure the maximum documentation components were met. Such teachings led our providers into migrating their focus from the true reasons for documentation and why it is important to a "bean-counting" conglomeration of words that checked audit boxes but didn't necessarily show the complexity of the encounter. 

All EMR did was come behind our mantra for max documentation components and say, "Hey, if that is all that is expected, then we can create efficiencies by making your paper templates electronic, instead of using a photocopier (copy/paste), instead of using transcription (talk-to-text), and instead of flip-flip sign dictation (electronic signatures)." See, we are doing the same thing we have been doing for years, only the technology advanced, and here we are with much of the same without a focus on the core purpose of what it is and why it's needed. 

Medical necessity audits by carriers have soared over the past few years, but the concept has been an integral part of E&M for 16 years. In 2004, Medicare changed the Claims Processing Manual (CPM) to reflect that medical necessity is the overarching factor. That was way before EMRs were dominating our practices. 

The Point: Medical necessity is not impacted by the 2021 E&M Changes. It will still be the overarching criteria, answering why the patient was seen and how complex was the interaction. Therefore, changes in how we score an E&M will have no impact on medical necessity, because it never had an impact on medical necessity. 

As we work our way through the rest of 2020 with the existing rules, it is important that we understand how E&M DG components work to convey the complexity of the interaction to naturally demonstrate medical necessity. The documentation components, if used appropriately, should work together to communicate the complexity of each encounter. The more complex the patient is, the more physical/mental work is involved, and more documentation is needed to communicate this. Review the chart below which shows medical necessity in conjunction with the documentation components naturally increasing as the patient's presenting problem increases in complexity. 






This chart clearly shows big change noted in the documentation requirements, but notice the correlation between medical necessity and the new MDM requirements for each level of service. Also noteworthy is that there is no variation from new to established patient for documentation content, medical necessity, or medical decision making. 



Preparation and Training
These E&M changes are much less intrusive than the implementation needs that were associated with ICD-10; however, if your providers have been using MDM to define their levels of service, or documentation only, then there is training and prep that needs to begin now. Medical necessity in conjunction with documentation requirements has been the rule since 2004, and since it does not change in 2021, all training and prep work that is done now should be implemented in 2020 as well.  

The following is a Training Prep Step-by-Step Guide to help implement these changes. 

Step One: This step is recommended for implementation February 2020.
Most providers have only been taught documentation requirements since residency. The best way to approach this change is to first conduct training identifying this requirement by Medicare in the Claims Processing Manual (link available in our website noted below). 
  • Be sure to define the difference in medical necessity and clinical decision for medical intervention. Inform the providers that complexity of care as demonstrated by the medical necessity is based completely on the documentation of each patient encounter.
  • Use the medical necessity tool found on the reverse side of the comparison chart to identify how to use medical necessity to select the appropriate level of service. 
  • Integration of current sample charts (HIPAA compliant) should be used as a hands-on session to practice what is learned.

Step Two: Shadowing is an extension of the hands-on application of Step One. This step should begin within 9-12 weeks of the completion of Step One. Completion should be approximately April 30, 2020, but may vary based on the size and difficulty of scheduling within your organization.
While most providers are not as receptive to shadowing during clinic, this exercise can be quite effective in another hands-on learning technique. Discussing the encounter, the complexities or the lack thereof, and identifying the best approach to documentation content focuses not on maxing out the requirements, but rather purposeful documentation to demonstrate complexity to support the most appropriate medical necessity.

Step Three: Review of documentation vs. coding. Upon maintaining the above pace for training, this step should begin around May 2020 and should be conducted over the following 4 months. Again, this may vary on sample size and organization size. 

Now it is time to evaluate the return on the training investment from Steps One and Two. Review 5, 10, or 15 records per provider. The sample size should be encompassing enough, but keep in mind this is validation of education and not meant to take the place of your annual compliance review. It may be prudent to show four main findings of each encounter for this review:

1. The level of service the provider selected
2. The level of service supported by the volume of documentation only
3. The level of service supported by the medical necessity only
4. The overall level of service that should have been billed to the carrier
Including each one of these will provide a basis for educating in proficiencies and deficiencies on selecting the level of service. Note that if your organization has been requiring MDM as the key indicator for the level of service, we would recommend having it as a main finding as well to educate on this difference.

Step Four: Feedback
No review (i.e., audit) is complete without feedback and education on any noted changes, why the changes were needed, and efficient strategies to implement for documentation improvement while maintaining patient care as the focus of each encounter. 65% of the population are visual learners, and by nature, many providers are analytical thinkers. Therefore, a combination of the two should lead to an effective educational approach.
• Of the records review, pull 2-3 samples and be sure to include examples of both incorrect and correct leveling of the E&M service.
• Handwrite on these HIPAA compliant records direct feedback by encouraging additional elaboration with key points and noting streamlining in areas in which over-documentation of the required components were noted.
• Be clear and confident in your findings and keep reminding the provider that the patient should look as sick or as stable as they appeared at the time of the encounter.

Step Five: Continue the review cycle and integrate 2021 changes.
Every 6-8 weeks, continue to provide spot reviews on the providers who need additional training for better compliance. During each 6-8-week period, begin the push toward 2021 prep. Using a HIPAA compliant office-based encounter, audit one of the notes using the current 2020 documentation requirements and medical necessity guidelines. Now, take the same encounter, and using 2021 rules, audit the same note for a cross comparison of the new guidelines. 

We are 9 months away and if your providers see an average of 4 patients an hour, in an 8-hour clinic day, for 3 clinic days a week, then they still need to create billable documentation for approximately 4,608 patients utilizing existing 2020 guidelines. This recommendation of phasing in the training will have your providers set and ready to go come January 1, 2021. 

Visit our website for free resources and tools to help train your providers.

We have created a one-page comparison of the changes between 2019, 2020, and 2021 that can be downloaded for free at www.namas.co/2021-comparison. 


Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA®, is the Founder and President of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the President of Coding & Billing Services and a Partner at DoctorsManagement, LLC.


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Deconda,  CPC, CPC-I, CEMC, CMSCS, CPMA, CMPM, CPMN

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