When most people think about the functions of a doctor, “coder” probably isn’t the first word that comes to mind. However, evaluation and management (E/M) coding plays a vital role in properly treating patients. A recent study found that, on average, physicians spent more than 16 minutes in their electronic health record (EHR) per patient on chart review, documentation, and orders.  

Given the amount of time doctors spend on coding, it is essential that they understand the changes planned for next year. These coding and documentation updates, made by the American Medical Association (AMA) and accepted by CMS, are designed to simplify the process so doctors can focus on caring for patients and nurturing the patient-physician relationship. 

What’s Changing in 2021?

For the first time in more than 25 years, the AMA is overhauling E/M codes for office and outpatient services. The changes will go into effect on January 1, 2021. According to the Association, “These foundational modifications were designed to make E/M office visit coding and documentation simpler and more flexible, freeing physicians and care teams from clinically irrelevant administrative burdens that led to time-wasting note bloat and box checking.” 

That’s good news for independent practices but requires some understanding to ensure a seamless transition. After all, in addition to the E/M changes, there are 206 new codes, 54 deletions, and 69 revisions to the Current Procedural Terminology (CPT®) code set, including many related to the ongoing COVID-19 pandemic. Modifications to E/M office visits include: 

• Eliminating history and physical exam as elements for code selection.
• Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time.
• Promoting payer consistency with more detail added to CPT code descriptors and guidelines.

Whereas the current E/M guidelines only allow physicians to code for an appointment’s length when more than half is dedicated to counseling or care coordination, under the new guidelines they can code and bill for these activities regardless of time spent just in counseling and/or coordination of care, but use the total time of the encounter on the date of service. According to Medical Economics, these activities include: 

• Care coordination (when not separately reportable)
• Counseling and educating the patient, family and/or caregiver
• Documenting clinical information in the electronic or other health record.
• Independently interpreting results (when not separately reportable) and communicating results to the patient, family and/or caregiver.
• Getting and/or reviewing separately obtained history.
• Ordering medications, tests or procedures.
• Performing a medically appropriate exam and/or evaluation.
• Preparing to see the patient (e.g., reviewing tests)
• Referring the patient to and communicating with other healthcare professionals (when not separately reportable).

What Do These Changes Tell Us About the Future of Healthcare?

Chronic conditions accounted for $1.1 trillion in healthcare spending in 2016, $3.7 trillion when “lost economic productivity is included”, which is approximately one-third of total healthcare spending. As care management for chronic conditions requires increased coordination and counseling, E/M ensures providers are rewarded for providing these services. As James C. Stevens, MD, and Ellen M. Gravallese MD noted in a recent op-ed in MedPageToday, estimates indicate that “Medicare reimburses physicians between three to five times more for procedural care than it does for equivalent time spent providing E/M services. This disparity has downstream impacts that limit patient access and contribute to workforce shortages in many specialties.” The revised guidelines and rules help to ensure this vital, valuable care is reimbursed adequately. 

Furthermore, the changes prioritize the patient-doctor relationship by rewarding time spent interacting with patients or reviewing their medical history. Certain EHR-related tasks are also now compensated. Research has shown increased (and often after-hours, unpaid) EHR usage is linked to physician burnout. Rewarding physicians for this necessary, if cumbersome, work may help to reduce stress. 

Preparing for 2021

Until artificial intelligence (AI) can completely and perfectly automate coding — and recent research suggests that won’t happen any time soon — doctors and staff must understand the 2021 coding changes. Failing to do so can lead to lower reimbursements or poor coding integrity, an issue that recently came to light when the Office of Inspector General (OIG) discovered $14 million in overpayments to Medicare Advantage plans.

With only a couple of months left in 2020, it is important that doctors and staff begin to familiarize themselves with the revisions. To ease the transition, the AMA has developed a helpful checklist, videos, modules, guidebooks, and extensive other tools and resources. 

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