In 2021, the AMA made some significant changes to the Evaluation and Management section of the CPT book.
Before this update, we were in between two sets of guidelines 1995/1997 guidelines which seemed burdensome to providers.
With the 95/97 guidelines, documentation requirements were heavy – requiring so many different components; HPI, ROS, PFSH, EXAM, DX, and ASSESSMENT/ PLAN
Providers said it was a lot of work documenting what was needed to reach those mid-high levels of E/M and see all of their patients.
In 2021 AMA made significant changes to the way we bill and E/M service
Updated guidelines
Now, providers can choose to bill via time spent on the encounter or by their MDM no longer does billing depend on the number of elements in the history and exam.
Billing according to time
When billing according to time, everything must be specifically documented in the note as well as the time spent on the encounter.
It is important to note that time does not have to be face-to-face with the patient. As long as the time is during the same date of service, it can be counted if specifically documented in the note.
It is also important to note that some payers will require start and stop times to be documented while other payers will say that total time is sufficient!
Billing according to MDM
When billing according to Medical Decision Making(MDM) we are looking at the following
- Number of diagnoses
- Amount of data
- Risk to patient
What is required to be documented?
The chief complaint must be documented this is what brings the patient in to see the provider!
History of present illness and past family social history needs documented a place to elaborate on the chief complaint. Medically relevant history is required to be documented
Review of systems – appropriate for the encounter should be documented
Physical exam – medically appropriate for the encounter
Assessment and plan – the diagnoses and what is being planned to treat or manage diagnoses
Signature – the medical record is a legal document and not considered finished until signed off by the provider performing the service. The encounter can not be billed until the note is signed.
Keep in mind that a medical record is a legal document and should be able to stand alone- meaning a note should give specific information regarding the encounter and should protect the provider in a court of law. The medical history and exam helps to prove medical necessity.
Medical necessity
How to prove medical necessity is by documenting everything in the encounter from the chief complaint to the A/P and everything in between!
Medical necessity is important because this is thr reason the patient needs treatment or diagnoatic testing.
Legal document
The medical record is also used for legal purposes in case of lawsuits. A provider note should prove medical necessity and the logic behind the plan a provider has.
If any portion of the note is missing, this creates gaps that can be detrimental to the provider in a lawsuit!
Even though we don’t bill it is required
We either bill according to MDM or time, but either way of billing still requires everything to be specifically documented.
- Chief complaint
- History of present illness
- Past family social history
- Review of systems
- Physical exam
- Assessment
- Plan
Learn more about E/M from the AMA here