Physician burnout has reached unprecedented levels in the United States.
A 2021 Mayo Clinic survey found that 63% of U.S. physicians reported burnout compared to 39% the previous year. As part of their Recovery Plan For America’s Physicians, the American Medical Association (AMA) strives to reduce the administrative burdens that lead to physician burnout.
In addition to initiating prior authorization reform, the AMA also revised the Evaluation and Management (E/M) clinical documentation. E/M services represent a category of Current Procedural Terminology (CPT) codes used for billing purposes. For decades, physicians have struggled with complex E/M code selection requirements.
In 2019, the CPT Editorial Panel, a workgroup responsible for maintaining the CPT code set, simplified the reporting guidelines for office visits and other E/M codes.
Beginning January 1, 2023, a third major documentation regulation change goes into effect for ambulatory service providers.
Here are five big takeaways for physicians and healthcare professionals:
1. The 2021 E/M office visit code revisions will apply to other E/M families of services.
In January 2019, as part of their “patients over paperwork” initiative, CMS revised several guidelines to simplify physician documentation, coding, and billing.
The AMA tasked the CPT Editorial Panel to revise E/M office visit code selection requirements to support this initiative.
The CPT Editorial Panel used a physician-centered, common-sense approach to develop the E/M revisions. They wanted the changes to be simple, practical, and clinically relevant.
Starting January 1, 2023, these family of services will follow the 2021 E/M office visit revisions:
- Inpatient and Observation Care
- Emergency Department
- Nursing Facilities
- Home and Residence
- Prolonged Services
Summary of 2021 Revisions for E/M Office Visits
They eliminated history and physical (H&P) as elements for code selection.
Although the panel determined that H&P contributes to a physician’s work captured in time and medical decision management, it should not be the key criterion to determine code selection.
They allowed physicians to choose Medical Decision Making (MDM) or Total Time.
This was a big change for physician and qualified health professional (QHP) documentation. It provided more flexibility with code selections.
In addition, Total Time amounts would better reflect physicians’ work times. Physicians and QHPs could count both face-to-face and non-facing services that occurred on the date of the encounter.
They used CMS tools and guidelines to modify MDM criteria for consistency.
To minimize disruption, the CPT Editorial Panel used the CMS Table of Risk and CMS Contractor Audit Tools to help design the revised required elements and level criteria for MDM.
They enabled physicians and QHPs to capture prolonged services in 15-minute increments.
This code is only reported with codes 99205 and 99215. It should only be used when time is the primary basis for code selection.
Starting in 2023, all of these E/M office visit revisions and more will apply to Inpatient/Observation, Emergency, Consultations, Nursing Facilities, Home and Residence, and Prolonged Services.
2. Emergency Department Providers (still) cannot use time as a code selection factor.
It’s too difficult to accurately estimate face-to-face time for patients in Emergency Departments.
Emergency department services are typically provided on a variable intensity basis when the same physician or QHP has multiple encounters with several patients over an extended period.
3. Providers will no longer use separate Observation and Inpatient CPT codes.
The CPT Editorial Panel deleted observation CPT codes and merged them into the existing hospital care CPT codes.
Also, they changed the code descriptors to reflect the merged codes and to reflect the structure of total time on the date of the encounter or level of medical decision-making when selecting code level.
4. Emergency Departments can select a CPT code when a physician or QHP may not be needed for treatment.
Some Emergency Department encounters may not require a physician or QHP present for the service, but there isn’t an explicit CPT code to reflect this level of medical decision-making.
The new CPT code description for code 99281 will reflect this level of care. Also, the other Emergency Department MDM levels will be modified to follow a linear progression, like office visits.
5. Providers can include both face-to-face and non-patient-facing work in their Inpatient Services total times.
When coding Inpatient Services, physicians and QHPs will count the total time spent on the date of the encounter.
Total time will include both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician and/or other QHPs on the day of the encounter.
This will include time in activities that require the physician or another QHP and will not include time in activities normally performed by clinical staff.
These pivotal E/M CPT revisions set the stage for physician-centered billing changes.
The physician community has struggled with burdensome billing documentation and reporting guidelines for decades. Historically, coding guidelines focused more on payor expectations rather than physician practices.
These E/M revisions reflect a physician-centered approach to developing coding guidelines. When making CPT Editorial Panel balanced payer rules with physician decision-making and patient care.
From prior authorization reform to common sense E/M coding, it’s important to simplify the administrative burdens in physician practices.
We need physicians focused on patient care, not checking off boxes.
To learn more about how Advantum can help your organization prepare for the 2023 E&M coding changes and stay compliant, click HERE.