Three Quick Tips to Get You Started with the New E/M Guidelines

In January 2020, the new 2021 Office/Outpatient Evaluation and Management (E/M) codes received much attention, generating excitement among physicians and coders. Finally, something promising to lessen the documentation burden!But then COVID and telehealth claimed the center stage and the 2021 E/M changes faded into the shadows. As we head into fall, the Centers for Medicare and Medicaid Services (CMS) published the 2021 proposed Physician Fee Schedule, and even though there is little fanfare, these changes are coming soon. To be clear, CMS is moving forward with most of the published changes, but there are still a few gray areas they will need to clarify before January. As a starting point, here are three quick tips to make the transition a little less painful.

Tip #1: Begin gathering information

While this seems obvious, now is the best time to ensure you have all the resources needed to make the transition. Accurate information is vital. A lot of inaccurate coding “folklore” is floating around. For example, rumor has it CMS will no longer conduct audits once these new guidelines go into effect, so there is no need to make changes. Not true! Another example is that the physician will no longer have to document a patient’s history or exam. Also, not correct. The physician will continue to document what they consider a “medically appropriate” history and exam to support their medical decision making. If you read an article (even this one!) or listen to a podcast, check the author references reliable sources. The following resources provide reliable, accurate information:

• American Medical Association: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
• CMS: https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-4
• Specialty Society websites

Tip #2: Plan for education

When new coding guidance is released, there is always an awkward balance between confusing physicians with information too soon and ensuring they are ready to go on the effective date. We recommend you start scheduling physician education for this fall at a time that facilitates maximum physician participation. The ongoing Public Health Emergency (PHE) forced us to embrace virtual forms of communication, education, and networking. One benefit of virtual learning is the availability and convenience to learn from home at any time. You can provide your physicians with a one-hour virtual session taught by a live presenter with the option for attendees to ask questions in real-time. With the opportunity to record, these sessions can be viewed later by those unable to attend. Another option is an online pre-recorded webinar that reviews the 2021 new guidelines. Although, I would only recommend this option to answer follow up questions if you have an in-house coding team. You can provide additional education as needed, but making sure you start everyone on the same page is crucial. Be sure to include your in-house coding team in your education plans! Invest in their knowledge base so they can better handle physician questions and continue to provide ongoing audits.

Tip #3: Update EMR templates

Throughout my twenty years of auditing, I have observed the good and the bad with Electronic Medical Record (EMR) documentation. The good: no longer trying to read horrible handwriting and the ability to locate records from any location. The bad: a document loaded with defaulted nonsense that affects the integrity of the note. Here is a golden opportunity to improve your EMR office templates while ensuring the physician note will support the new 2021 guideline requirements.

• Help the physician “work smarter, not harder.”
• Ask for their input on what seems “medically appropriate” for the history and exam.
• Give physicians clear guidance on where to document total time spent (one of the two options for code selection) and what verbiage to include.
• Update the wording in the Assessment and Plan of the office note to best support Medical Decision Making (the second of two options for code selection).

EMR updates are especially critical for medical groups that have been using a “code calculator” for office E/M code selection. Beginning in January 2021, the code the calculator recommends will no longer be accurate as they heavily relied on history and exam elements. Also, changing templates may require involving your EMR vendor, your internal IT team, or both. The template changes take time. Be sure you plan now. Change is hard, even when it is good. As we all know, a delay is the deadliest form of denial. Plan now to reap all the benefits!

Next Steps

• Request a checklist to prepare for the 2021 E/M changes
• Listen to a podcast: Major E/M Coding Changes Coming in 2021: Here’s What You Need to Know
• Submit your questions on the upcoming changes and how to navigate the new guidelines