Prioritizing Patients Over Paperwork and the E/M Coding Reforms

There has been a change proposed by CMS that would increase the amount of time clinicians and doctors can give to their patients by reducing the hassle of unnecessary paperwork, which they normally have to go through for billing Medicare. These changes intend to improve the healthcare system all over the country. They would also restore and improve the relationship between the doctor and the patient by allowing clinicians to maintain EHRs (electronic health records) for documenting meaningful information pertaining to the patient instead of simply noting data for the purpose of billing. Various payment and coding changes have been proposed by CMS in order to reduce the administrative burden and to improve the accuracy of billing for E/M patients (that is, patients receiving evaluation and management services). The summary of the proposed changes is mentioned below.

Proposed Changes to Coding

Medical practitioners will be allowed to choose to document outpatient or office E/M visits on the basis of time or medical decisions rather than simply applying the current 1995 or 1997 E/M guidelines for documentation. Similarly, medical practitioners would also be allowed to simply keep using the present framework instead of making any changes if they so choose. When selecting the visit level and when documenting the E/M visit, practitioners would be allowed to use time as a governing factor. This would expand the current options, even if counseling or care coordination was the purpose of the visit. The proposed changes will result in the expansion of the current options with regards to documenting the history as well as the exam. As a result, practitioners will be able to focus on the documentation of the patient to understand what has changed or has not changed since their last visit rather than documenting all information again without any analysis. This will also encourage them to update and review the patient’s current and previous details. These changes will allow practitioners to simply use the information for the purpose of reviewing and verifying rather than entering it again, which would have already been done by the ancillary staff or the beneficiary. There are also possibilities of the documentation guidelines that help facilitate medical decision-making being changed in the upcoming years.

Other Proposed Changes

CMS has proposed the idea of a single blended payment rate for both new and established patients for the outpatient or office E/M level 2 all the way to level 5 visits. It also proposed a series of add-on codes for the resources used to provide primary care and non-procedural specialty services. This would possibly result in the improvement of the accuracy of payment systems and the simplification of the process of documentation. Another proposed change is that there should be a minimum documentation standard for Medicare to support a level 2 CPT visit code for the exam or history of the patient or for medical decision-making. For the latter situation, the practitioners could prefer using the current framework or, as suggested, the documentation of the E/M level 2 to level 5 visits of patients. In those instances where time is used to document E/M visits by practitioners, it is proposed that they make a note of the medical necessity of the patient’s visit and document the total amount of time they spent with them. Practitioners also have the option of documenting any extra information needed for various purposes such as legal, clinical, and operational. It is also expected that if they are documenting additional medical record information for such purposes, it would be consistent with the level of medical care that was given. However, as a requirement, only that information is necessary which supports the purpose of the patient’s visit and is associated with the current level 2 CPT visit code. The additional information is not a necessity but can be added to facilitate further treatments and care. The CMS has also proposed that there should be a multiple procedure adjustment payment system that should be used when patients make an E/M visit as well as serviced with different procedures in the same visit. This would make the payment process more efficient. New coding would also be used to differentiate podiatry E/M visits from normal E/M visits. This would help identify and value these services. A new face-to-face and prolonged E/M code is also proposed along with technical modification to the practice expense methodology. Another change that would be seen is the elimination of the need to justify a home visit. CMS also suggests a policy that can eliminate or prevent any kind of payment for the same-day E/M visit by many practitioners who belong to the same specialty in a group practice. Furthermore, CMS seeks to eliminate any duplication in the documentation which may already have been a part of the patient’s medical records due to other members of the medical team. Currently, CMS is looking for public suggestions and recommendations on the possible implementation of these updates to the E/M visit coding system and documentation. According to CMS, this is a great proposal that would give practitioners great flexibility to exercise clinical judgment in the process of documentation and for focusing on what is relevant clinically and what is absolutely necessary for the beneficiary. Hence, this would allow practitioners to give all their attention to their patients and care instead of documenting redundant and unnecessary information.