News: AMA on track to revise E/M codes, set new documentation guidelines

CDI Strategies - Volume 13, Issue 12

The American Medical Association’s (AMA) current procedural terminology (CPT) editorial panel approved sweeping changes to documentation and code selection guidelines for evaluation and management (E/M) codes. If finalized, the changes will shift the way practices select codes for both office and facility visits as soon as January 2021, according to the Revenue Integrity Insider.

The editorial panel-approved changes include several items that would directly affect physician documentation requirements and how charts are coded:

  • Deletion of level 1 office new patient E/M code 99201. Medicare claims for code 99201 represented only 0.15% of all 266 million inpatient E/M claims in 2017, and yet it had a 37% denial rate versus an overall E/M denial rate of 5%.
  • Removal of history and exam as key components for selection of the E/M service level. The practitioner would be required to document that these elements were performed in order to report an office visit code.
  • Practitioners would select E/M codes based on either the level of medical decision making (MDM) or the total time spent performing the service on the day of the encounter.
  • A plan to revise the E/M guidelines into three sections:
    • Guidelines common to all E/M services,
    • Guidelines specific to office and other outpatient visits, and
    • Guidelines specific to E/M services in the facility setting, including observation, hospital inpatient, consultations, emergency department, nursing facility, domiciliary, rest home or custodial care and the home setting.
  • Total time would include “total time spent on the day of the encounter,” instead of total face-to-face time.
  • A major overhaul of the MDM documentation guidelines to emphasize complexity of the conditions being addressed in place of the number of diagnoses reported.

The CPT editorial panel is seeking comments on the proposed changes through March 25. All the details are available on the AMA CPT website.

Editor’s note: To read more about the proposed changes, read the coverage from the Revenue Integrity Insider. To read about previous E/M documentation requirement changes, click here.

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