Blog, Chirosecure Live Event September 30, 2020

New Outpatient E/M Reporting Rules for 2021 – Mike Miscoe

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Hello everyone. This is Michael Miscoe with Miscoe Health Law for this week’s installment of a ChiroSecure’s Facebook live presentation. And this week we’re going to talk about new outpatient E/M reporting rules that go into effect January of 2021. Um, for those of you that, uh, report evaluation management services, uh, for outpatient, uh, encounters, uh, new patients, nine nine two Oh one through nine nine two Oh five established patients nine nine two one one three two one five. Um, there is a rather, uh, elaborate, um, ad hoc scoring methodology, uh, for those services based upon history, uh, examination, medical decision making, and the alternative being where you can build those, uh, evaluation management services on the basis of time, but only where counseling or coordination of care, uh, accounts for more than 50% of your face to face time with a patient, uh, performing evaluation management work.

Um, now those are the rules for the existing, uh, services, um, and starting 2021, the outpatient E/M services only. So all the inpatient stuff, consults, uh, eat emergency department and all of, uh, hospital observation, all those other kinds of E/M services, they’re staying with the same scoring methodology. Only the outpatient E/M services, uh, scoring are going to be changed. And, and the change is rather significant going forward rather than history exam medical decision making. Um, the, uh, codes are going to be Redis griped in, uh, CBT as being based upon either medical decision making only, or time only. Um, and what makes that significant is, um, I don’t know if it’s making things better or making things worse and, and the CPT editorial panel has published some rather intricate guidance, uh, relative to, uh, how you evaluate medical decision making, how you evaluate time, what time counts, um, and it is going to blur the lines so to speak, um, as to, uh, what you can bill as levels of E/M.

Now, uh, time seems to be the easiest, a couple of things you have to remember about time. Um, there’s a number of things, you know, in terms of documenting your time, you have to first remember that the code requires as part of its description or the new codes will require as part of their description, a medically appropriate history and an examination. So it’s not like you get the punt entirely on the history and exam. Um, and I, the history and the exam helps set the stage for what is considered medically necessary, uh, in terms of time spent with a patient or what, what can you do [inaudible] we should consider when we’re evaluating medical decision making. Now let’s start with time first, because I don’t know that it’s easier or harder. Um, and, and I apologize, we only have 10 minutes. This is a 90 minute lecture, but, um, uh, long story short time is total time.

So it includes both face to face time and non-face-to-face time. So if you’re doing a analysis of records prior to the patient encounter, but on the day of the patient encounter that time counts, um, if, um, then of course, here’s your medically appropriate history and examination, the time you spend face to face with the patient, if you have to coordinate care with other providers that counts things that don’t count, um, things that would normally be done by ancillary staff. And this gets a little tricky because they don’t explain, well, what happens if the doctor does it? So let’s say in many practices, uh, medical and chiropractic, um, a staff member takes the history of present illness, or even the patient, you know, does their own history well, that time wouldn’t count, but what if, if you’re a practice where you do all that stuff personally, does it count then?

Well, they don’t tell us that. And, and hopefully there’ll be some more guidance coming out to resolve that little situation. But I think any time you spend performing document performing medically a medically appropriate history and exam, um, as long as it’s not irrational, like you take two and a half hours to do it, um, that’s probably going to be acceptable. Um, some other things that don’t count the time you spend, uh, interpreting images and writing reports, if you’re billing for that time, as part of the professional component of say an x-ray, then that time doesn’t count for E/M purposes. So you only get paid for that time once. Um, if there’s time for coordination of care, like team conferences, not like you, probably any, whatever, build those. Um, but you know, that time doesn’t count, um, any, uh, uh, otherwise you need to document your time spent in each activity.

So if you spent 15 minutes reviewing the patient’s records prior to their, um, their visit, let’s say in an initial encounter and the patient, uh, sent records ahead of time. Um, and you’re reviewing that stuff before for you visit with a patient, then you need to record that time. You need to record your face to face time in any other non-face-to-face time. If you’re a practice that likes to do an initial and then follow up with a report of findings, because that generates too many E/Ms and is likely to subject you to audit you now have an incentive if you’re billing your evaluation management services on the basis of time to do that report of findings at the initial visit. So maybe with patient scheduling, you allow more time for initial patient visits to give you time, you know, go through the history exam stuff that you would normally do.

Um, review films, any diagnostics, sit down with a patient layout care options, whatever you’re going to do, and then document that time accordingly. Now, interestingly enough, completion of the note is also reportable time. And the question is, has been raised since the publication, these rules, you know, are docs that are two finger typers in their EMR system, assuming you’re using EMR. Do they get paid more because it takes them longer to document or no? And, and the answer is maybe, um, just make sure that again, you’re not, um, you know, taking a coffee break between each keystroke in order to, to, to buff out the time. Um, so one other interesting thing about time is that the time hacks for a new patient and established patient codes are, uh, you know, understandably different when we get to the medical decision making, we’re going to find that medical decision making is consistent level two through five, regardless of whether it is a newer established patient, which suggests for the same work on a new patient visit, you’re going to get paid the same as if it’s an established patient visit, which doesn’t seem to make sense, especially since new patient E/Ms on the time side, you’re doing more work, more time for a new patient visit at one level versus an established visit at another.

I’m talking about medical decision making. There are still three components of medical decision making, diagnosis, management options, data, and risk. Uh, however, they’ve combined them into one table. And there’s, there’s a number of ambiguities in terms of condition classification. Um, but in some cases is a medical device. As you’re making may get you a higher code, maybe not, but, um, the, the doctor documentation has to be more precise specifically for each condition that you review and the history and exam, you should load that into your assessment. And I’m not talking things like neck pain and subluxation. I’m talking about a subluxation, a cervical radicular, Titus, preset, syndromes, you know, all your itises off of these and whatever sprains strains, and you need to indicate what the status of that condition in terms of, is it self limited or minor that you’re not actually going to treat it?

Is it acute on complicated? Is it chronic with progression because, um, otherwise it’s not going to be clear how that, uh, your condition should be counted for purposes of now analyzing that first element of medical decision making Jada is pretty easy to understand when you look at the guidance of the thing is you get, you get a point for ordering an X Ray, and you also get a point for reviewing one. Uh, the question is, is if you’re reviewing one that you ordered and you’re reviewing it on the day that you’re also billing for the professional component of the x-ray, you get the data points. I’m unclear on that yet we’ll have to wait for more guidance. And in the absence of guidance, you may have to draft your own policies, um, to, to figure out how you’re going to handle that. But I don’t see data driving the train on medical decision making anyway, finally risk.

Uh, we have the same risk scoring that we had before, except that used to be a big table with three columns. Now it’s just the third column of the old risk table. And, uh, chiropractic care being conservative measures is, is always going to be low risk unless you identify, um, some form of risk factors or comorbidities, um, how, what impact they have, they’ve thrown in some criteria for social determinants of health, uh, you know, position the patient and without clarifying how they impact, uh, the risk or the decision making overall. So, um, we’re just about out of time, you know, we’d love to walk you through an intricate detail, but we don’t have the time, but as you look at these new codes, understand they go in place January one, um, there’s data out on the AMA website explaining the changes. Uh, you need to review those so that you’re ready to go live and you can figure out what changes you need to make in your documentation relative to your initial visits, progress, evaluations, and whatnot.

And whether it behooves you to take advantage of time, um, or, uh, to, to, to look at documentation for medical decision making. And it means you’re going to have to push your EMR vendors because they’ve got to change the structure of your documentation to fit which way you want to go. Now, the choice you, the path you take, isn’t unilateral, you, you don’t have to always go with time or always go with medical decision making. You can go back and forth as, as the case dictates, but you need to be able to document, um, uh, in your EMR record, hopefully without too much extra typing. Um, you know, if you’re going time, what you spent time on specifically, you know, this category of things, this is what I did, and it was this many minutes. And then total it up at the end or medical decision making where conditioned classifications, uh, the status.

Is it improving? Is it exacerbated? And all that stuff become critical to being able to evaluate medical decision making. Hopefully this gets you interested in doing some, uh, analysis and research before these changes take place, because you don’t want to get blindsided coding under the old system, uh, when the codes have changed in CPT. So this is a rather significant change, a little bit of a heads up, try and stay ahead of the curve. And hopefully, um, you know, we’ll have some more time to talk about, uh, specifics, but, uh, don’t be frustrated when you read the rules or some things you’re not going to understand. Um, and only because I don’t understand them either, so don’t feel bad and I get paid to evaluate this stuff. Um, but hopefully, uh, as we illustrate those ambiguities to CBT, uh, we’ll see what they do, and then we’ll have to wait and see what CMS does to see if they, you know, uh, deal with time and medical decision making the same way CPT does. So a lot left to, um, uh, figure out before the end of the year, uh, stay tuned and as updates come along, we’ll pass them your way. Uh, but for now, start looking at these changes and figuring out how you’re gonna, uh, deal with your documentation so that you can appropriately get credit for the E/M work you’re doing. That’s all we have time for today. Hope that was informative, and we’ll see you next time.

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