May 31, 2023

E/M Coding Changes Reshaping the Physician Note in 2021

  • By Eva Johnson,
E/M Coding Changes Reshaping the Physician Note in 2021

The change in the code descriptors and guidelines for the evaluation and management (E/M) services delivered during the office visits and other outpatient encounters grant an opportunity to rethink about the outpatient documentation and reduce the physician’s workload.

Barbara Levy explained that “the code changes will only be applicable to the E/M in the outpatient and office settings and not for the inpatient, home care or nursing home E/M”. Barbara Levy is the MD, former chairperson of the AMA/ Special Society RVS Update Committee (RUC) and Co-chair of the AMA-convened workgroup that held coding overhaul, was also a webinar specialist and she described the workgroup’s principles as “clinical importance will always be the priority, the new code will help in removing all the unnecessary things from E/M services.”

Dr. Levy, also explained about the AMA Current Procedural Terminology code set that AMA will continue to work on the proposals for the inpatient settings also.

MDM Coding with Reduced Variations

The whole concept of code selection components was narrowed to only two, which are, MDM (Medical Decision Making) and total time on the day of the encounter.

Dr. Levy also said that the workgroup modified the MDM criteria to make them more intuitive according to clinical importance as well as to reduce the variations between the contractors and payers by excluding the vague terms like ‘mild’.

Some of the elements of the MDM affecting the coding for the outpatient or office visit are as follows:

  • The number and complexity of the problems addressed in the encounters are held as unnecessary in documenting every diagnosis a patient has received instead only those being addressed during that visit.
  • The amount of complex data to be reviewed and analyzed. This will also enable physicians in reducing the copy-pasting note bloat by not requiring to enter the large volume of repetitive test data that are mostly irrelevant or ancillary to the purpose of the visit.
  • Risk of complications or morbidity of the patient management. This can also help in including the social determinants of the health and other reasons behind the decisions for not admitting a patient or any kind of intervene in admitting the patient.

Dr. Levy exclaimed that risk of complications or morbidity component of MDM is only to represent “what is going on with the patient”.

This also involves the factors determining the patient’s social life which helps in assessing the viability of a healthcare plan.

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