2021 E/M Changes: What (Other) Areas of Your Organization Have Been Impacted?

2020 was a momentous time in healthcare. Last year, the landscape of healthcare changed significantly as we adapted to telehealth services as a routine vehicle for providing healthcare because of COVID-19. Additionally, many organizations transitioned their workforce to remote work environments. Amid those changes, for the first time in nearly 25 years, new evaluation and management guidelines have been implemented effective January 2021. Since then, AAPC Audit Services’ efforts have been largely focused on education, training, and auditing organizations’ success on the implementation of the new guidelines.

The Patients Over Paperwork Initiative was launched by CMS Administrator Seema Verma with the goal of cutting the red tape of burdensome regulations, while increasing the efficiency and improving the patient experience, all in an effort to make healthcare more patient centric. A study published in the Annals of Internal Medicine reported that primary care physicians spend 27% of their time on clinical services and 49% of their time on administrative functions. That 49% of time on administrative functions is adversely affecting clinicians and contributing to physician burn-out.

There are different components to the Patients Over Paperwork Initiative, but in this eBrief series we will focus on revisions to the E/M guidelines. The goal of the Patients Over Paperwork Initiative was to reduce the administrative burden for practitioners, allowing them to focus more on the patient and less on paperwork. This was meant to be achieved by reducing documentation requirements such as HPI elements, ROS, or past family social history. Practitioners’ primary focus should be clinical care of the patient. The goal is to move away from the check-box methodology of leveling an office visit, and direct more focus on medical decision making.

The 2021 E/M guidelines eliminate history and exam as required elements of leveling a visit. With the new guidelines, clinicians now only need to document a clinically relevant history and exam. Code selection is now based on medical decision making or total time spent on the day of the visit. For the last year, the healthcare industry has focused largely on educating providers, billers, coders, and auditors with the “how” part of implementation of the guideline changes. In an article published by MGMA in October of 2020, 47% of Healthcare leaders say their practice was prepared at the time. Which leaves 53% of organizations only a few months ago who considered themselves unprepared.

The American Medical Association published an article called “10 Tips to Prepare Your Practice for E/M Office Visit Changes.” The article gave some very practical information on how organizations can plan for the operational, infrastructural, and administrative workflow adjustments that will result from these changes. What is the impact of these guideline changes beyond coding and documentation?

EHR / RCM System Preparedness

Beyond coding and documentation, one of the areas impacted by the 2021 E/M guidelines is Electronic Health Record (EHR) and/or Revenue Cycle Management (RCM) system preparedness. With the landscape of provider documentation requirements changing along with the addition of new CPT codes, the deletion of 99201, new time parameters, and the change in leveling criteria for existing office outpatient CPT codes, system optimization becomes crucial. The American Medical Association (AMA) worked very closely with EHR Vendors and other stakeholders leading up to these changes. CMS also announced in the final rule that they would adopt the AMA CPT code changes with some exceptions.

Additionally, commercial payers are required to adopt the E/M office visit code revisions. The CPT code set has been adopted as the standard medical data code set for physician services. The 2021 E/M guideline updates are now part of the CPT code set. Health plans are required by HIPAA to use the most recent version of the medical data code set. Payors, to whom services are submitted for reimbursement, are adopting the 2021 E/M code revisions, so we can expect that EHR and RCM vendors are adopting the CPT codes set as well. There are both additions to, and deletions from, the code sets that are affected by the guideline changes, as well as significant changes in time ranges. It is imperative that your EHR is updated with the most current code sets to ensure both accurate reporting and reimbursement of services.

Many EHR’s use automatic coding applications within the system to make recommended code assignments. Changes in logic within these applications are necessary since the history and exam are no longer key elements used in code selection. Additionally, the data is calculated very differently and there are no longer designations of new or established problems with or without workup. Ultimately, correct code selection corresponding to the medical record documentation should be reported regardless of whether changes have been made in coding logic.

Provider documentation templates will also need to be updated. Outpatient office visit E/M code selection in 2021 is based on either total time spent or medical decision making. Providers no longer need to worry about documenting a certain number of elements of HPI, review of systems, past family social history or a certain level of exam for code selection, this is not to imply that these elements do not have to be documented, but documentation now defers to what the provider deems clinically relevant. In addition, the guidelines specify changes in time parameters for the outpatient office visit code sets. Provider templates updated with the new time parameters along with specification on how that time is spent will guide providers in accurate documentation and reduce missed opportunities for reimbursement.

Organizations that perform other E/M services (e.g., consultations or inpatient evaluation and management services) need to bear in mind that they will be using the 95/97 guidelines for those services. Can your EHR accommodate all the services your organization provides with the applicable guidelines? Even though the history and exam are not required elements when leveling an outpatient E/M services in 2021, a clinically relevant history and exam is necessary, and the information provided is still used to arrive at the correct code selection, so these elements cannot be skipped in the documentation.

Coders and auditors frequently use information from the whole note to arrive at the MDM level. For example:

    • What is the patient's current smoking status?
    • What are the patient’s comorbidities?
    • What medications is the patient taking?
    • Are there social determinants that affect the patients’ access to care or health status?

This information ultimately aids a coder or auditor in deciding a patients’ level of risk. It is important that provider templates reflect the new guideline changes but do not hinder accurate code selection either. Claim edits is another area likely to be affected by the new guidelines. Both claim edits and provider templates are affected by the new prolonged service codes. CMS did not adopt the AMA’s prolonged service time recommendation, so we have not only two different codes for prolonged services, but two different time applications when it is used. It is recommended that your EHR recognize both payor and time to ensure accurate code selection for prolonged services.

EHR / RCM systems frequently have claim edits for payor guidelines related to consultations. As a result of the 2021 guidelines changes, consultations can no longer be crosswalked to outpatient E/M codes.

Diagnosis code specificity is also an area of importance that may be affected by claim edits. With medical decision making now being one of the two driving leveling forces for office outpatient visits, accurate and specific diagnosis code selection is extremely important. There is a difference between an “acute, uncomplicated” versus an “acute, complicated” diagnosis, or a “stable chronic illness” versus an “exacerbation of a chronic illness.” For example, the difference between unspecified chronic obstructive pulmonary disease and an acute exacerbation of chronic obstructive pulmonary disease or an unspecified contusion versus concussion with loss of consciousness is often the difference between a low and moderate nature of presenting problem.

When auditing services, we commonly see organizations not include each diagnosis code that affects a patient’s care on the date of service. Using the correct diagnosis code(s) communicates the clearest picture of medical necessity to payors, which may remove potential claim denials or pre-payment requests for medical records.

Hopefully, at this stage, your EHR / RCM vendor has made system updates and provided you with details of those updates. Payors will need to ensure their system is also prepared. It is anticipated to see discrepancies for quite some time between provider organizations and payors being at varying levels of readiness. For this reason, we strongly recommend review of codes prior to claim submission ensure accuracy and close monitoring of claim denials and reimbursement.

Revenue Cycle Impact

The 2021 E/M guideline changes will affect organizations in unique ways based on payor mix, specialty, payor contracts and coding and documentation practices. Clearly, specialties that are heavy in office-based services are going to be more affected. Surgical based practices will be less unaffected by the changes. For those organizations that are, we can assume a couple of different things at this stage. First, these changes are being implemented amid a public health emergency. The revenue cycle is already impacted by COVID nationwide. Many organizations now have employees performing critical components of the revenue cycle who have been transitioned to remote working environments. That includes providers. CMS allowances for changes in originating sites means providers can perform telehealth services, at least during the PHE, from their home. I think it is safe to say that the Revenue Cycle has already been significantly affected aside from the E/M guideline changes.

Patient scheduling may not seem like an area that would typically be affected by these changes, but this component of the revenue cycle, in my opinion, is affected now that visits can be based on time or MDM and more importantly that choice can be made from visit to visit. How is patient scheduling affected in your organization?

    • What is the complexity of problems among patients?
    • Are there certain presenting problems that may lend more toward billing based on time?
    • Are there a certain number of problems addressed at a visit where billing on time is advisable?
    • Are there patients whose visits take longer for various reasons?

Having managed medical practices for many years, I know all too well that changes in provider schedules is not something that can happen spontaneously. These guideline changes affect the complexity of patient scheduling and this is certainly a discussion that needs to be had and may require a little trial and error to come up with what works best for your organization.

One of the certainties with these new guideline changes is that it is going to take providers and coders some time to adjust to the documentation changes and coding methodologies. That may affect your charge capture time. For organizations that find themselves coding heavily on time, you may find that your charge capture time is less. Now that time has been expanded to include total time spent by the provider including documentation time, there is incentive to complete dictation the same day as the visit. Regardless, anything new has an adjustment period.

Coding is another area of the revenue cycle impacted by the guideline changes. Whether charges are coded by providers or coders, the changes in documentation could be quite significant. Not only can visits now be leveled on time or MDM but the AMA has provided us with some definitions for the components of MDM that we did not have before. While those definitions are intended to provide clarity and eliminate subjectivity, the new guidelines do place a heavier responsibility on coders to understand disease processes. The 2021 E/M guidelines established new time parameters. We recommend organizations have an audit process in place to review coding to ensure accurate application of the guidelines. Whether this means you have an internal audit process or use a 3rd party vendor, it is still your organization's responsibility to ensure accuracy. This audit process could extend your total days in AR for a period. AAPC Services did their own 2021 Case Study that compared coding practices under the 95/97 guidelines as well as applying the new 2021 E/M guidelines and that study was very revealing. There is an increased risk of under-coding with the new guidelines changes particularly for certain specialties so it is very important to have an audit process in place.

Claims submission is the revenue cycle component where claims are scrubbed. It is anticipated that RCM systems will create new claim edits incorporating the 2021 E/M guideline changes. It may take billers some additional time to adjust to those new edits. We can expect new edits for time and certainly for the new prolonged service codes. Additionally, payors will have to decide if they are using the AMA’s or CMS’ definition for prolonged services so a claim edit comparing prolonged service code to payor is not unexpected.

Certain specialties we are going to see a shift in coding patterns with the new guidelines. We can anticipate payers will be analyzing some of those larger shifts. It is not unreasonable to assume payers will be instituting more pre-payment reviews and requesting medical records to validate medical necessity, particularly where we see high utilization of 99205 or 99215 and use of the new prolonged services code. There is an increased risk of audit as we see coding patterns shifts.

An industry concern worth consideration is the downstream effect on risk adjustment with resulting changes in documentation from E/M guidelines changes. With reduction in documentation requirements there are considerations that need to be made on how the documentation changes affect how services are valued from a risk perspective.

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Key Performance Indicators / Benchmarks

It is unclear in the industry right now how these guideline changes are going to affect benchmarks or key performance indicators. What is clear is that many organizations use national data published by other organizations to establish benchmarks. The inherent problem with this is that there is always a lag and benchmarking surveys do not always reflect what is happening at the present moment. Surveys being published now will typically reflect data from the previous year or even 2 years past. The previous year was far from normal. Is it fair to evaluate how well your organization is implementing new E/M guidelines based on data from a year with a public health emergency? Where does that leave us when evaluating our performance in 2021.

HFMA is recommending an alternative method of benchmarking. Rather than using outdated benchmarking data that is not relevant to the current situation, the alternative method is to look back at your own historical data. Gauge where you have been and analyze where you want to be for optimal performance.

If your organization is going to use benchmarking data then geography must be acknowledged as a contributing factor. Different parts of the country were affected differently by COVID, when looking at national benchmarking data we do not have one size fits all.

Benchmarks and KPI’s are going to be affected by this huge shift that we all experienced last year. We saw the landscape of healthcare shift significantly with the expansion of telehealth services but also the transition of thousands of jobs to remote working environments. It is important to analyze your KPI’s frequently.

I believe one of the keys to success is to get key performance indicators into the hands of front-line folks in the organization. Traditionally, we see benchmarking data and key performance indicators in the hands of gatekeepers. Getting data into the hands of providers, front and back-end managers, even front-line staff creates a direct tie from the work they are performing to the financial results of the organization. It creates a higher level of investment on behalf of the boots on the ground employees and often, those are the folks that really translate the data into something meaningful.

Work-Flow Impact

Who do the changes in the E/M guidelines predominantly affect in the organization? I think without a doubt, #1 is providers but that is followed closely with other back office clinical staff, coders, and auditors. While these changes are, in part, aimed at creating a more patient-centric environment by reducing documentation requirements they also affect work-flows throughout much of the organization.

The work-flow of providers is a key area of impact. In an E/M Revisions study, the AMA estimates that over 2 minutes can be saved per visit with the implementation of the new E/M guidelines and reduction of documentation requirements. Effective training of the new guidelines, system optimization through updates to documentation templates, and change in provider documentation habits and practices is necessary to achieve this. Providers can choose each visit to bill based on what is most advantageous, time or MDM. If they choose to bill based on time, that time includes not just time spent seeing the patient but also time spent reviewing diagnostic tests, coordinating care with other providers, ordering labs or other tests, and dictating among other things. The code billed can only reflect time spent on that day. If your organization has providers whose work-flow is to perform some of these functions on different days you may want to re-evaluate their process.

Does time saved with the decrease in documentation create an opportunity for providers to see more patients? This will vary provider to provider and will be a work in progress to identify what works best for your organization. The back office work-flow for medical assistants and nurses may change some if the provider is billing based on time. Information that may typically be gathered on the day of the appointment such as labs, diagnostics, and medical records may need to be obtained the day prior or several days prior to ensure the provider has time to review on the date of service to get adequate credit for time.

The potential for under-coding is now an even more heightened issue. Coders and auditors need to allow for change in their work-flow as well. If providers are doing their own coding, initially this may mean more intensive review of documentation to ensure code accuracy. It is anticipated more time will be spent reviewing the documentation through the lens of the new guidelines. Many organizations are performing smaller, more frequent audits to validate the accuracy of coding with education of the providers and coding staff. Whether performed internally or by a 3rd party vendor, this may be something your organization wants to consider.

Key Take-Aways

    1. Knowledge is power and it is safe to assume that we have not seen the last of the changes to the E/M guidelines. The question still lingers what guidelines revisions are expected for inpatient E/M services. By monitoring how the outpatient E/M guideline changes affected organizations we stand much to gain by understanding how these changes affect revenue and work-flow. Assess where your EHR / RCM system is at with the new CPT codes and changes to logic for both code selection and claim edits.
    2. Keep a close eye on productivity of providers and coders. AAPC services is conducting a time study with our own team of auditors to evaluate the effect on productivity applying the new guidelines. It is far too early to release results of that study but from what we have seen industry wide, these changes are extremely difficult for everyone to implement and it is taking more time, at least initially, to code and audit these services as we build our muscle memory.
    3. Review your benchmarks and key performance indicators closely. Share the information within the organization so everyone can understand the impact they have on the whole process.
    4. Lastly, we strongly recommend that you incorporate quick check audits, whether that is with a 3rd party vendor or internally. These are not full-scope audits that includes all procedure codes, modifiers, or ICD-10 codes. The focus is on the understanding and implementation of the new guidelines. It is far better to find out early on that you have issues than get several months down the road after revenue has been affected or bad patterns have been established that require correction.


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