This is the year for many changes in healthcare and the physician coding changes that were announced in March 2021 are just one piece of that.

Evaluation and Management services (E/M) have not seen a change in more than 25 years; however, this year has significant changes for the office and outpatient locations. These physician coding changes impact more than just the leveling of an office visit.

With the 2021 changes, we now have two methods of reporting a service in these locations. Although they appear to be somewhat familiar, they are in fact very new and different. The documentation and coding guidelines have been redefined completely.

This redefining process impacts so much more than just what level best represents the complexity of the presenting patient; it also impacts how we document the service and reimbursement. In order to ensure we are capturing all E/M services appropriately in the office and outpatient setting, three specific areas must be assessed.

3 Areas that can Impact Physician Coding

1. Technology

The first area is in the functionality of the Electronic Health Record (EHR). The way our EHRs are currently set up, may not be the most efficient as we implement these physician coding changes.

Some important questions need to be asked:

• Are you currently able to capture all of the new elements needed to code by time correctly?
• Is your template designed in a manner that allows for documenting within the assessment and plan in enough detail to easily determine the complexity of medical decision making?

These are just a couple of the technological items to evaluate this year to reduce and/or prevent any denials and to support capturing the appropriate documentation in the most effective manner.

2. Quality Control

The second area to look at is how you intend to monitor the quality and/or accuracy of your coding and billing practices. Do you have an internal/external auditing plan in place to audit the documentation and physician coding practices based on the new changes?

Not only should we monitor the accuracy of coding, but we should also be looking to identify any inefficiencies, trends and opportunities that could have an impact on the organization.

3. Education

The third area is education. The documentation and coding changes are significant and require not only physician but coder education. In order to support reporting the appropriate level of service, the assessment and plan must be specific and detailed enough to support all conditions being evaluated and treated on a given date of service.

Evaluating each service based on time or medical decision making alone is new to all providers and should be thoroughly reviewed with providers and coders as we implement the new e/m changes.

Provider/coder education is essential to your organization’s success. These educational services are designed to optimize front-end and back-end billing functions. Blue will customize training by specialty and can be delivered at the group level or at the individual provider level. Training can also be customized based on specific audit results. This training can be conducted onsite or via video call; annually and on an ad hoc basis.

Learn More About Physician Code Changes

To learn more about the changes surrounding evaluation and management, leveraging your current technology, auditing and education, contact your local Blue & Co. Advisor or reach out to a team member listed below.

Charlie Eckert, Manager

Angela Page, Senior Manager