Otolaryngology Coding Alert

Taking the time to revise forms/templates pays dividends in the long run.

The time has come to toss aside the overly complex 1995 and 1997 evaluation and management (E/M) guidelines that rewarded quantity over quality. No more shall providers feel forced into documenting history and physical exam elements they feel aren’t pertinent to a visit just to support the E/M level that is medically necessary and appropriate.

Background: Coding and documentation for E/M services carry fewer administrative burdens in 2023 as landmark reforms that were implemented in 2021 for E/M services performed in outpatient and office settings have been carried over across all healthcare settings, including hospitals, emergency departments, nursing facilities, and patient homes.

If you want to ensure your practice is prepared for the major E/M overhaul, but are not sure where to begin, keep reading. Here is a breakdown of what you need to know and do to ready your office for 2023 and beyond.

Brush Up on the E/M Evolution

In 2021, the Centers for Medicare & Medicaid Services (CMS) began moving away from a points-based system for history, exam, and medical decision making (MDM), to a medical necessity-based system, which requires documentation that stresses MDM or time. Broadly speaking, under 95/97 rules, for each service provided, “there were points and bullets that had to be documented in the history, exam, and MDM in order to support the level of service the physician felt was medically necessary,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey. MDM has always been the arbiter, though; a thorough history and exam would not procure top reimbursement for a simple case of postnasal drip.

“But with the 95/97 guidelines, a complex case could easily have been downcoded for want of one missing bullet documented, such as family history, even though every other requirement had been met,” Cobuzzi notes. She went on to explain that “as a result, forms and templates grew to support the 95/97 guidelines to help ensure that no element needed to support higher-level services would be missing from the chart, should the medical necessity of the patient’s problem(s) dictate a higher level. The result was a chart filled with extraneous information, most of which was not used to treat the patient, nor did it add to the quality of patient care.”

Changes to E/M coding in 2021 included providing physicians and other qualified healthcare professionals (QHPs) the flexibility to select a level of service for an outpatient visit

based on the complexity of MDM or total time on the day of service — including work completed when the patient wasn’t present. And once Jan. 1, 2023, is in the rearview mirror, these revisions to leveling methodology extend to the remainder of the E/M sections.

Get Rid of the Junk

MDM has always been part of the algorithm for choosing a level of service but will now be the sole determinant (unless the provider intends to bill based on time). Many anticipate that this conversion to basing code level on MDM will require significant changes to physician behavior and documentation, as they no longer have to capture information in the history and exam not needed for patient care but collected in the past to fulfill 95/97 guideline requirements.

With CPT^® removing all references to level of history and physical examination from code descriptors and replacing them with a “medically appropriate” history and exam, the note can home in on the presenting problem instead of the three key components. This shift in focus to medical necessity and MDM means it is no longer necessary to include extraneous information not relevant to the medical issues at hand in the documentation.

The key term to note here is “medically appropriate” history and exam. In other words, it is the provider’s responsibility to perform the extent of history collection and examination that they consider medically necessary for that patient at the time of the visit.

Impact: Gone are the days of counting bullets to determine the extent of the history and physical exam. Now, your otolaryngologists only need to include what they deem relevant based on the reason for the encounter. Their efforts should now be geared toward supporting the E/M level based on MDM or total time.

Stress to your providers that the new rules do not constitute a diminution in documentation requirements or a reduction of supporting facts for a given diagnosis. In fact, AMA, CPT^®, and Medicare are raising the bar on the quality of documentation for a given diagnosis.

Modify Your Forms and Templates

As guidance evolves, so must your processes and technology. So be sure to review your E/M templates on a regular basis. This is crucial, as many upcoding/downcoding issues can be traced to the poor design of templates that auto-populate or pull information from previous visits without having the provider validate that it is pertinent to the current service.

If your practice is one of those who are still using intake forms and templates based on the 95/97 guidelines, consider modifying these tools to avoid wasting effort on superfluous info. Work on creating new templates in your electronic health record (EHR) system that de-emphasize bullet points for review of systems, history, and exam; and instead, emphasize elements of MDM and gather more details about the presenting problem, as well as facilitate tracking time spent on activities related to patient care.

Don’t Forget Education and Audits

The updates outlined above should be accompanied by training and education to ensure physicians and coders alike have a firm grasp on the definitions of problem types, risks, and other elements of services that are needed to substantiate MDM; as well as best practices, such as routinely documenting items within notes that will be used to score MDM, including ordering/ interpreting tests or imaging, reviewing outside documents, and having discussions with other healthcare providers.

Routine reviews of E/M documentation are essential, as well. Use test patients to practice utilizing your new templates/ coding levels and self-audit. This will help you determine how they would score using the new MDM parameters. Every compliance plan should have a program outlined to review provider documentation on a regular schedule to evaluate the effectiveness of training and ensure templates are being used and edited correctly. Annual reviews are recommended, with more frequent inspections of the outliers.

Hear What Industry Experts Have to Say

The E/M overhaul is a welcome change. Before the switch, in order to bill codes, such as 99222 or 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate/high complexity …), “there had to be a comprehensive history and exam; otherwise, the visit would have to be downcoded,” Cobuzzi notes. “Now it lies on MDM, which orients things toward the patients.”

CPT^®’s primary objectives for the 2023 reforms were threefold. “Our No. 1 job was to make it simple, practical, and clinically relevant — you call that administrative simplification. Our No. 2 goal was to decrease the need for audits or to fight fear. No. 3 was to decrease the unnecessary documentation that was related to coding and not to clinical care and get rid of the junk,” according to Peter Hollmann, MD, chief medical officer of the Brown Medicine faculty medical group and AMA CPT^® Editorial Panel member.