This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

Those who know me best know that I am an absolute optimist. I can find the positive in almost everything. So, what has this stay-at-home order impacted?

  • We slowed our lives down
  • We saw what it is like to be a teacher
  • We realized how much toilet paper we use when we are all at home
  • We realized how scary these times are

    I am not downplaying the seriousness of this unprecedented time and my heart goes out to all who have been affected by this terrible pandemic. I just want to speak to the glass being half full and what we can build from during this terrible time.

    What is the hidden positive in all of this from a coding perspective?
    I know everyone was looking forward to figuring out how you were going to teach all your providers how to convert to the 2021 E/M guidelines. Because of the COVID-19 crisis, CMS has started that dialogue for you already!
    Source: https://www.cms.gov/files/document/covid-final-ifc.pdf
    Well, let’s take this lead and run with it! I know many are struggling with getting the video and telephone visits all documented appropriately. The providers are able to obtain a very limited exam based on their ability to see the patient over webcam or phone video. It is very interesting how much you can really do by only looking at a patient. One of our team came up with some different body systems that can still be examined this way. It allowed us to think outside the box, which will be part of the new normal.
    I know all who are using an EHR system have seen a provider copy and paste forward the exam from the previous visit and only update what has changed since the last visit or not update it at all. So, in 2021 CMS is reducing that clinical burden by allowing the providers to focus on what has changed since the last visit or on pertinent items that have changed rather than re-documenting information. This is provided that the provider reviews and updates the previous information!

    The provider can also review and verify information that is entered by ancillary staff or the beneficiary rather than re-documenting it all. So, in 2021 CMS and CPT are eliminating history and physical exam as required elements for code selection. The encounters will be based on Time or Medical Decision Making (MDM).
    “On an interim basis, we are revising our policy to specify that the office/outpatient E/M level selection for these services when furnished via telehealth can be based on MDM or time, with time defined as all of the time associated with the E/M on the day of the encounter; and to remove any requirements regarding documentation of history and/or physical exam in the medical record. This policy is similar to the policy that will apply to all office/outpatient E/M’s beginning in 2021 under policies finalized in the CY 2020 PFS final rule. It remains our expectation that practitioners will document E/M visits as necessary to ensure quality and continuity of care. To reduce the potential for confusion, we are maintaining the current definition of MDM. We note that currently there are typical times associated with the office/outpatient E/M’s, and we are finalizing those times as what should be met for purposes of level selection.”

    Counseling and/or coordination of care will no longer be required to dominate the visit to use time as the controlling factor. Time will now be a time range instead of typical time. Time will now be TOTAL time spent by the physician or other qualified healthcare professional (both face-to-face and non-face- to-face). This will not include the time spent by the clinical staff to obtain vital signs or recording history, etc. This is a new concept for the providers, and we will need to help them understand this change. Time also needs to be carved out for minor procedures, EKGs, and other office diagnostics, and for explaining risks and benefits and obtaining informed consent for surgical procedures. These changes are only applied to office or outpatient services (99202-99215). Remember that code 99201 will be deleted in 2021.

    MDM for 2021 will now include the number and complexity of problems addressed during the encounter, amount/complexity of data to be reviewed and analyzed, and risk of complications, morbidity and/or mortality of patient management decisions made during the encounter.

    There are four levels of MDM: straightforward, low, moderate, and high. I am not going to go into each one, but I encourage you to go out and get the new table of risk that was published so you can see the changes and start to get familiar. I would also encourage all to sign up for all the education you can get on the new 2021 E/M changes as repetition will be our greatest teacher. If we are well-versed then it will be easier for us to transfer our knowledge to the providers.

    I encourage all of us to follow CMS’ lead. Use this as the first building block to the new normal. It is early in the year and time is already flying by as we are staying so busy with COVID-19. As you discuss these telemedicine visits with the providers, go ahead and watch for opportunities to insert those new changes coming up. Don’t lose the momentum that has already been generated.

    I hope all of you stay safe and healthy and take a minute to thank all the front-line healthcare providers and other essential workers – truck drivers, restaurant, grocery, and convenience store workers who are keeping us stocked up. Kiss your family and let them know how precious our lives are and how quickly all has changed. May God bless you all.

This Week’s Audit Tip Written By:
Kari is Senior Manger, Coding Quality- Auditor & Educator for INOVA in Falls Church, VAWhat to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email [email protected].
  2. Read more: What can you expect from a coding and compliance review?
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