Podcast Episode 2: Outpatient Office Coding 2021
Episode Summary: New medical documentation guidelines for Outpatient Office visits were implemented on January 1, 2021 as part of the “Patient’s over Paperwork” initiative by Medicare with input from the American Medical Association. These new documentation guidelines require a “medically appropriate” history and physical exam and are billed by either Total Time or Medical Decision Making. Host Neal Sheth interviews Dr. Piyush Sheth regarding these guidelines including benefits and pitfalls and their impact on healthcare economics.
Resources:
AMA 2021 E/M Office visit changes:
E/M office visit changes (ama-assn.org)
AMA updated document regarding Outpatient Office visits:
Code and Guideline Changes | AMA (ama-assn.org)
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Hosts: Neal Sheth, CGSC; Piyush Sheth, MD, FACS, DABS, CGSC
NEAL SHETH: Welcome back to another episode of Unraveling Medical Coding. Today we will focus on Outpatient Office Coding for new and established patients. This does not include office consultation coding, which will be discussed in a future podcast episode. New guidelines were implemented January 1st, 2021. Why was that needed?
PIYUSH SHETH: The original documentation guidelines from 1995 and 1997 from CMS, the Centers for Medicare and Medicaid Services, laid out a blueprint for selecting a coding level of service based on the amount of documentation of three elements: history, physical exam, and medical decision making. The more bullets you hit in each of the elements, the higher level of service you could bill at. For example, a level 3 billing code required a detailed history, a detailed physical exam, and a low level of risk for medical decision making.
In instances where counseling and coordination of care took more than 50% of the time for the office visit, providers could use time instead of the three elements to select a billing code.
The criticism from office-based providers was that documentation was too burdensome. “Patients over Paperwork”, an initiative of CMS, led to a significant overhaul of the billing code requirements for office and other outpatient services and went into effect on January 1st, 2021. The goal was to reduce documentation requirements, allow for time-effort recognition, and to better reflect the current practice of medicine by reducing burdensome regulations that impede a clinician’s ability to spend time with patients. The new guidelines were developed by the American Medical Association with approval by CMS and rely on either Total Time, or, Medical Decision Making, to be used in billing code selection. Although a history and physical exam should be documented, these only need to be “medically appropriate”, and that is determined by the provider.
NEAL: What do you think of this simplified history and physical exam requirement where you as the provider determine “medical appropriateness?”
PIYUSH: For most providers, this will lead to easier and less burdensome documentation for office visits. However, there are situations where a provider may still need to document a rather comprehensive history and physical exam.
If a physician evaluates a patient in the office and schedules that patient for a surgical procedure, there may be certain documentation requirements mandated by credentialing or regulatory agencies that would have to be followed. For example, if I see a patient in the office for an umbilical hernia, according to the current documentation guidelines, I would only have to document “Patient presents with a mass at the umbilicus causing pain, on exam he has a reducible mildly tender umbilical hernia, plan is to proceed with laparoscopic umbilical hernia repair with mesh under general anesthesia and I discussed the risks with the patient and he wishes to proceed.” However, most hospital medical staff bylaws require a full history and physical exam be documented prior to a major surgery and those bylaws usually list out all the requirements, such as heart and lung exam prior to a major surgery. The Joint Commission as well also requires that “medical history and physical examination…should be relevant and include sufficient information necessary to provide care, treatment, and services required to address the patient’s condition, planned care, and assessed needs…A History & Physical must be completed and entered into the medical record for any high-risk procedure, surgical procedure, and any procedure that involves anesthesia services.” In this example, you can see how the new documentation guidelines can seem to be at odds with certain regulatory requirements.
NEAL: Let’s switch gears and talk about selecting a billing level code. You said this can be done using Total Time or by Medical Decision Making. Can you explain this further?
PIYUSH: Selecting a billing level can be done by Total Time or by Medical Decision Making. I’ll talk about Total Time first since it’s the easiest to discuss. Each billing level code has an associated time range. In the past, Total Time was defined as only face-to-face time with the patient. The new definition for Total Time includes both face-to-face time with the patient and non-face-to-face time spent by the billing provider on the day of the encounter. The new definition excludes time for activities performed by clinical staff. Let’s break this down. Face-to-face time is the time you are with the patient performing the medically appropriate history and physical exam and any discussions with the patient or their family, guardian, or caregiver. Non-face-to-face time is time spent preparing for the visit such as looking through the patient chart to gather information, reviewing or entering data into the medical record chart, ordering tests, medications, or other services, reviewing or interpreting test results, or referring / communicating / or coordinating with other healthcare providers. You cannot, however, include time that your clinical staff spends performing other activities such as taking vital signs or scheduling surgery. Also, you cannot include time that you spend on another day performing any of the above tasks. It must be time spent on the same day of the encounter.
NEAL: That definitely sounds easier than the previous method and seems to be more practical. What about using Medical Decision Making instead to select a billing level.
PIYUSH: This is a little trickier but, in my practice, I almost always use Medical Decision Making when selecting a billing level. Medical Decision Making is broken up into three elements:
Problems
Data
and, Risk
Let’s look closer at each of those three elements.
Element 1, Problems, refers to the Number and complexity of problem(s) addressed. Problems can be self-limited or minor; acute; chronic; new problem undiagnosed with uncertain prognosis; or an illness that poses a threat to life or bodily function in the near term if not treated.
Acute problems are further subdivided into a) uncomplicated, b) with systemic symptoms, or c) complicated. Chronic problems are also further subdivided into a) stable, b) with exacerbation / progression / or treatment side effects, or c) with severe exacerbation / progression / or treatment side effects.
An example of a self-limited or minor problem would be a pimple. A new problem undiagnosed with uncertain prognosis would be diarrhea of unknown etiology. Unfortunately, there are no nationally published databases stratifying problems into these categories so for the most part we use medical judgement.
Element 2, Data, refers to the Amount and complexity of data reviewed or analyzed. It deals with ordering tests, review of test results, review of external notes, assessment requiring an independent historian such as a parent or guardian, independent interpretation of tests performed by another provider, or discussion of test interpretation or management with another provider.
Element 3, Risk, refers to the Risk of Complication or Morbidity and Mortality from Patient Management, Diagnostic Testing, or Treatment. For example, management of prescription drugs is considered a Moderate Risk whereas a decision regarding major surgery with patient or procedural risk factors is considered a High Risk.
When selecting a billing level based on Medical Decision Making, you only need two of the three elements. You would obviously want to use the two elements that minimally qualify for the highest billing level.
NEAL: That definitely seems more complicated that using Total Time. So why do you mostly use Medical Decision Making in your practice?
PIYUSH: Total Time is hard to accurately document. In fact, your documentation should reflect the tasks you performed during the time you are claiming. You might be documenting in the patient’s electronic medical record chart when you are interrupted by a phone call that is unrelated to that patient’s management or you are called away to see another patient before you return to the patient’s chart to complete your documentation. It is difficult to calculate total time unless you wear a stopwatch. Now imagine seeing three patients at the same time in the office. Do you really want three stopwatches that you are constantly trying to manage? How are you going to document what tasks you performed? What if you are busy but don’t get a chance to review labs and X-rays until latera in the day? What if you don’t get a chance to document on the same day? This method seems highly fallible and prone to abuse. One can imagine a scenario where a provider can easily claim more time was spent that was actually spent and it would be difficult to audit this.
I personally feel that the Medical Decision Making method for coding and billing is more accurate as well as being easier to audit. Once you practice with the Medical Decision Making method, it becomes more intuitive.
NEAL: Are there any other pitfalls in using the new documentation guidelines?
PIYUSH: Yes, there are many other pitfalls when you read the fine print in the guidelines. I’ll give you two examples.
In the first example, lets zero in on the Medical Decision Making Element 2. Data. When you order a test on one day, it includes the subsequent review of that test result. If I see a patient on Monday and order a Hemoglobin level, and then see the patient back on Wednesday to review the test results, I can only take credit on one of those days for the data element. I cannot take credit on both of those days.
Another example is the definition of a chronic stable problem in Element 1. The fine print in the guidelines includes the following statement: A patient that is not at their treatment goal is not stable, even if the condition has not changed and there is no short- term threat to life or bodily function. As an example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. This patient would then be classified under chronic problem with exacerbation, progression, or treatment side effects which bills at a level 4 billing code. But a patient with poorly controlled blood pressure is not really an exacerbation, progression, or treatment side effect.
NEAL: Yes, I can see how there can be confusion. What can providers and coders do to overcome this?
PIYUSH: There really is only one way. Providers need to spend time learning the new guidelines and read the fine print. It is tedious but, in many ways, it is simpler than previous guidelines. To put things in perspective, the new guidelines are in a 16-page document. The 1995 and 1997 guidelines combined were a 95-page document.
NEAL: What’s your take on how the new guidelines will affect the economics of healthcare since we are talking about billing.
PIYUSH: When using the 1995 and 1997 guidelines, the bell-curve distribution of billing code usage centered around the level 3 codes. Since the implementation of the new guidelines, I have seen my curve shift towards higher level codes. I suspect that office-based physicians will see a similar shift and this will mean that our healthcare system with have higher expenditures. Only time will tell how that will affect our economy.
NEAL: Thanks for explaining outpatient office coding. Check out the notes section of this podcast where you’ll find a link to the AMA website that has the new guidelines.