E/M coding changes

[AMEHigh]

Are you or your organization doing anything to prepare for the new E/M changes?

I’m in a leadership role now and have brought this up to billing and IT, but no one seems to have a plan.

The AAFP keeps sending out info and ideas about how to get prepared, but my org seems to be casual about this.

So which one is it? Do we need to prepare or is it no big deal and we’ll just figure it out on Jan 2021?

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[deleted87716]

We have a coding class next week.

 

[door_to_balloon_knot]

I think the biggest takeaway I’ve seen so far is it will be okay to document less in the History and Exam portions of the note as they will no longer be relevant for the EM code; it will be based on solely on MDM. Still need to document what you need for medicolegal purposes but ideally a lot of the bloat is supposedly cut down (e.g. copy and paste labs, imaging, previous portions of HPI from past notes, etc.)

Here’s is what the pessimist in me sees
happening. A lot of peeps (especially consults) will still document the way they always have and be surprised when they get down-coded after relying on Hx and Exam to hit that sweet 99205/-215 without the MDM. On the other end of the spectrum we will get terrible **** notes and bloated assessment/ plans that are hard to decipher based on the Hx and Exam.

 

[deleted87716]

I think the biggest takeaway I’ve seen so far is it will be okay to document less in the History and Exam portions of the note as they will no longer be relevant for the EM code; it will be based on solely on MDM. Still need to document what you need for medicolegal purposes but ideally a lot of the bloat is supposedly cut down (e.g. copy and paste labs, imaging, previous portions of HPI from past notes, etc.)

Here’s is what the pessimist in me sees
happening. A lot of peeps (especially consults) will still document the way they always have and be surprised when they get down-coded after relying on Hx and Exam to hit that sweet 99205/-215 without the MDM. On the other end of the spectrum we will get terrible **** notes and bloated assessment/ plans that are hard to decipher based on the Hx and Exam.

I’m already dealing with consultants who basically copy and paste their HPI into their A&P and somehow think that’s OK. And then, they write an additive note which basically is a copy and paste of every HPI and A&P one after the other going forward into infinity.

 

[Vandalia]

OK I am an old curmudgeon, but if I was ever elected U.S. Medical Dictator my first act would be to disable the ability to "cut and paste" on any EMR.

If it is worth knowing, it is worth typing.

 

[VA Hopeful Dr]

OK I am an old curmudgeon, but if I was ever elected U.S. Medical Dictator my first act would be to disable the ability to "cut and paste" on any EMR.

If it is worth knowing, it is worth typing.

Depends. If you mean literal copy/paste exclusively, I'm with you 100%.

I have a number of macros and whatnot that I use for a fair number of patients identically. Basic stuff that I can automatically do on every patient that I use to hit the minimum billing requirements for level 4 visits. Stuff like "not agitated, no respiratory distress, normal heart rate, no scleral icterus". I hit one button to get my "from the door" exam findings.

 

[Vandalia]

Depends. If you mean literal copy/paste exclusively, I'm with you 100%.

I have a number of macros and whatnot that I use for a fair number of patients identically. Basic stuff that I can automatically do on every patient that I use to hit the minimum billing requirements for level 4 visits. Stuff like "not agitated, no respiratory distress, normal heart rate, no scleral icterus". I hit one button to get my "from the door" exam findings.

Correct I mean literal "cut and paste." Macros are still "typing" in my book since you have to actually stop and think about the concepts that you are including in the record.

 

[deleted87716]

If you’re in primary care, and doing chronic disease management follow up visits every 3 to 6 months, the patient frankly doesn’t change all that much from one visit to the next. Copying forward makes perfect sense, assuming that you actually take the time to read your previous note and make any changes/addendums that are required. Ultimately, you have to read your own notes.

 

[Reboa]

Not to be too pessimistic but we lost blended payments which would have increased primary care salaries significantly and are stuck with decreasing documentation requirements. Which is great on paper and will have an impact on easing primary care documentation burdens, but as many have said will essentially allow the subspecialists that we need to actually document their thought process and exam findings to not be incentivized to do so. Oh and now we have complete transparency in our documentation to the laypublic which when taken out of the context of a medical education will add headaches to many physicians days. I'm all for greater transparency in medicine, but we can only take so many moral injuries from so many different parts of medicine before future medical students are completely disincentivized from this field.

 

[deleted87716]

blended payments which would have increased primary care salaries significantly

You lost me after that.

 

[door_to_balloon_knot]

If you’re in primary care, and doing chronic disease management follow up visits every 3 to 6 months, the patient frankly doesn’t change all that much from one visit to the next. Copying forward makes perfect sense, assuming that you actually take the time to read your previous note and make any changes/addendums that are required. Ultimately, you have to read your own notes.

HTN, HLD, BMI Class X is a favorite combo. Stable for all 3 (meaning the patient hasn’t done jack ****).

Thank you, come again Mr./Ms. 99214. At least there are some efficient things that make primary care worth it.

 

[sloh]

HTN, HLD, BMI Class X is a favorite combo. Stable for all 3 (meaning the patient hasn’t done jack ****).

Thank you, come again Mr./Ms. 99214. At least there are some efficient things that make primary care worth it.

Playing sisyphus pays

 

[FutureInternist]

OK I am an old curmudgeon, but if I was ever elected U.S. Medical Dictator my first act would be to disable the ability to "cut and paste" on any EMR.

If it is worth knowing, it is worth typing.

Not when you have multiple outside labs dictated into pt’s chart, or a “running total” of the micro or cultures etc.

Like guns, it is the lack of thinking when using copy/paste that kills.
Don’t take it away from the ones that use it correctly.

 

[nexus73]

As a psychiatrist I won’t be reducing any of my documentation so these changes don’t help me at all. I can’t due to liability and need to document important info for me and others who read my notes. Please just pay me more. Or provide some liability protection. Or something actually meaningful.

 

[gguerrab]

I saw all the AMA videos, read the 2021 guidelines and wrote an article in my blog and summarized into a video.
> 2021 CMS E/M CODES REVISION FOR OFFICE AND OUTPATIENT SERVICES
I even created an app with an algorithm based on the AMA Elements of Medical Decision Making table and time.
> E/M Coder

I actually think I spotted an error in the document that AMA published with the final coding guidelines changes.
When coding by time and you exceed the time allotted for a 99215/99205, they state:
"To report a unit of 99XXX, 15 minutes of additional time must have been attained. Do not report 99XXX for any additional time increment of less than 15 minutes."
But then, this table in the last page shows that you can bill for a 99215/99205 + 99XXX with a time range just a minute over the level 5 visit.
Shouldn't the range be like?:
New patient, time: 89-103 min = 99205+99XXX(X1)
New patient, time: 104-118 min = 99205+99XXX(X2)
New patient, time: 119-133 min = 99205+99XXX(X3)
Established patient, time: 69-83 min = 99215+99XXX(X1)
Established patient, time: 84-98 min = 99215+99XXX(X2)
Established patient, time: 99-113 min = 99215+99XXX(X3)

Am I missing something, or did they actually messed up?