Earlier in the year, I summarized the upcoming changes for 2021: Link Get Ready for 2021 Coding Changes (with links to AMA resources and tables). Subsequently, I went to a coding seminar led by Jan Rasmusen and wanted to share some additional observations.
- One of the most important changes is the need for “medically appropriate history and/or examination” rather than focusing on specific elements. This helps eliminate scoring the history and physical exam and should allow more time to document critical thinking. Besides billing, H&P is still key for helping with continuity of care and for liability.
2. When using time codes and not using medical decision-making, the total time –face-to-face and non face-to-face –is what is used. Total time does not include clinical staff time.
3. A lot of the terms have more specific definitions
4. Medical Decision-Making is Similar to Current Guidelines
5. Creation of a new code for additional time
My take: The intent of these changes is logical. The goal of coding is to align the reimbursement with the degree of effort and not simply allow pre-formatted templates to justify upcoding. These changes could lead to simplification of documentation and allow more documentation time for medical decision-making part of the visit.
- 2021 E/M changes: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
- AMA E/M learning module: https://edhub.ama-assn.org/interactive/18057429
- AMA MDM table (see below): https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
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