How’s it Going?Evaluation and Management 2021
Judith L. Blaszczyk RN, CPC, ACS-PM, ICDCT-CM We are now in Q3 with putting the 2021 E&M guidelines into practice to document and select the levels for our outpatient/office visits. The promises made for these changes were “Patients over Paperwork” and “Reducing Provider Burden.” At first glance, it all seemed simple. Providers, coders, as well as administrators were looking forward to eliminating the need to include unnecessary information in the medical record to meet the bulleted requirements for each element of a visit. The good news is that the AMA has worked hard to fulfill these promises, and Medicare has agreed to accept the new regulations. Also, the increase in work relative value units for office/outpatient services and the last-minute boost in the conversion factor have resulted in an 8% increase in reimbursement for pain management providers when reporting these codes. As ACE has begun to audit records for 2021, we have made some interesting observations. In many instances, the “note bloat” that was supposed to disappear with the new rules’ implementation is still present. The practice of “copy and paste” or pulling information forward from previous encounters remains. Although we have seen some groups adding a statement about the time spent with the patient, no real attempt at meaningful revision to documentation has been noted. To benefit from the time-saving capability of the 2021 rules, providers will need to be open to change and be willing to invest in revising their visit templates. The previous formatting does not lend itself to capturing the new definitions for time-based reporting or the more clearly delineated elements for documenting medical-decision-making. To facilitate the ability to choose either method, (depending on which is more beneficial to the provider), the template must have the capacity to capture the necessary information for both models. | 
