Latest Changes in Coding and Documenting E/M Services and What’s Coming

Hopefully by now you have all heard about the efforts that are being made to streamline E/M coding and documentation. The process providers need to go through to meet criteria when documenting their patient’s visits has been an unremitting chore. Instead of just making a note which discusses the patient’s issues and their treatment, the provider has the arduous responsibility of proving system or organ reviews, patient history and medical decision making. Keeping track of medications, related medical issues, drug interactions and other patient information while trying to meet the demands of a busy practice had caused documentation overload, resulting in physician frustration and burn out.

CMS has implemented the final rule that spans from January 1, 2019 through December 31, 2020. The rule allows physicians to focus their documentation on what has changed with an established patient since that patient’s last encounter. It eliminates any requirement for re-documentation on any of the required E/M elements, as long as there is evidence that this information was reviewed and updated. Providers are also no longer required to document the medical necessity of a home visit in lieu of an office visit.

In a plan to further reduce the documentation burden for providers, CMS is creating changes to the way providers code, bill and document their evaluation and management office and outpatient services. Beginning January 1, 2021 payment for E/M office and outpatient visits will be simplified and there will be a significant change in the way providers code. CPT 99201 will be deleted. The way 99201-99205 and 99211 through 99215 are coded will change. Right now, the level of E/M coding is based on three key elements: history, exam and decision making. Starting January 1, 2021, providers will choose the level for office and outpatient E/M codes based on either medical decision-making only or total time only.

These policies should grant practitioners increased flexibility to carrying out clinical conclusions in documentation and facilitate the freedom to focus on what is clinically pertinent and medically necessary for the patient. For more details and more information on this, please visit Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019.