The 2021 E/M code changes — changes to the evaluation and management visit code — went into effect on January 1, 2021. These updated coding guidelines represent the most sweeping revisions to the code since 1997 and are focused on relieving some of the administrative burden on doctors and medical staff by simplifying coding.
This comes as good news to most medical providers, since 90% of them are using electronic health records (EHRs) to track patient visits. While EHRs were supposed to help doctors reduce time spent on paperwork, instead they ended up taking up to 49% of a doctor’s day — and evening — while only 27% of time was being spent on face-to-face patient care.
Not only does this tendency take away from a provider’s ability to serve patients, it also represents a significant monetary burden on the system. (this link talks automation too)
The new coding requirements will help physicians simplify the complexity of patient encounter notes and make it easier for offices to leverage automation to streamline processes, reduce unnecessary information, and present full and accurate information for better patient care and medical decision making (MDM)
Here’s what you need to know about the new changes.
How to Manage the 2021 E/M Code Changes Seamlessly
Before you can manage the 2021 E/M code changes in your office, you need to have a basic understanding of the overall goal and direction of the guidelines:
The Biggest Change
The most impactful changes that providers will notice in the new coding guidelines is that E/M documentation will target time and medical decision making (MDM). Under the new guidelines, details of patient history and exams are only captured when it is clinically appropriate, using time or MDM, whichever is most appropriate for the visit.
MDM Under the New Guidelines
The new guidelines are written from the perspective of a clinician to clear up areas which in the past had been “gray areas”. The new guidelines will:
- Align criteria with clinically intuitive approaches
- Use current content management system and third-party tools to reduce issues with coding patterns
- Create detail in Current Procedural Terminology (CPT) to reduce payer inefficiencies
- Remove ambiguous terms
Under the new guidelines the amount of the visit that is conducted and recorded is up to the provider and will not be a consideration for code selection. Code selection instead will be based on what is actually done in the office setting.
The Importance of Time
Under this code, time includes both face-to-face and non-face-to-face. Summarization includes the total time spent that day and the services that were performed. Importantly, time:
- Doesn’t require the patient to physically attend a visit in the office
- Does not include time incurred by clinical staff
- Does not include time spent conducting procedures
- Does include time spent by non-physician providers (NPPs) but can only count one person per minute of time spent.
- Includes reviewing test in preparation for a patient appointment
- Includes education or counseling time for patients, families, and caregivers
- Includes ordering medications, procedures, or tests
- Includes time for documentation work performed at home.
Using a robust enterprise content management system (ECM) or document management system (DMS) can assist physicians and administrative staff in further simplifying documentation under the new code.
For example, the ability to access appropriate documents securely when and where you need them is critical to maintain high levels of efficiency. When doctors or staff must use after-hours time at home to catch up on documentation, a DMS simplifies the process and ensures access to EHRs is granted to authorized personnel only.
Perry proTECH — Providing the Tools You Need to Manage Better
At Perry proTECH, we know that health care providers need to maintain operational efficiency and provide a high level of patient care. While this can seem like a daunting proposition, it is made much easier by the 2021 E/M code changes — and the ability to harness the potential of powerful technologies such as document management systems.
Our team of IT experts can help your office optimize workflows; capture, modify, share, and store documents for use by authorized personnel when they need them; and automate processes where appropriate to reduce inefficiencies.
Using a robust DMS, your office can take full advantage of the coding changes and ensure a seamless transition to a more productive, profitable business model.
Manage the 2021 E/M code changes with ease. Contact a Perry proTECH consultant and learn how our document management solutions can support your office today.