Excerpted from page 44 of the May/June 2021 edition of AOA Focus.
Coding and documentation for evaluation and management (E/M) services saw significant changes at the beginning of the year that build on the movement to better recognize the work involved in non-face-to-face services, such as care coordination. As of Jan. 1, E/M codes need to be selected based on what is more appropriate: medical decision-making or total time—not a patient’s history and physical.
Previously, total time could be reported by itself only if more than 50% of the time with the patient was for coordination of care or counseling, but now, time can qualify on its own. It is imperative to remember that doctors still need to document what is medically necessary for patient history and the exam. While some of the extensive documentation requirements that were in place previously have been relaxed, it remains vital to document thoroughly for medico-legal purposes, quality reporting requirements and also to retain a complete understanding of the patient medical history, issues and needs.
While how time is considered has changed, it is critical to remember that usage of the prolonged service modifier also has changed. Under the new guidance, a doctor must reach the highest level of E/M before one can add the prolonged service code. It is critical to understand:
- When time is being used to select the appropriate level of a service, the time personally spent by the physician assessing and managing the patient on the date of the encounter is summed to define total time.
- The appropriate time should be documented in the medical record when it is used as the basis for code selection.
- Physician/other qualified health care professional (QHP) time includes the following activities, when performed:
- Preparing to see the patient (e.g., review of tests).
- Obtaining and/or reviewing separately obtained history.
- Performing a medically appropriate examination and/or evaluation.
- Counseling and educating the patient/family/caregiver.
- Ordering medications, tests or procedures.
- Referring and communicating with other health care professionals (when not separately reported).
- Documenting clinical information in the electronic or other health record.
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
- Care coordination (not separately reported).
Remember: QHP time does not include staff time.
Helpful coding resources
If you have questions regarding these code changes, please contact the AOA’s Coding Experts.
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