Overview of AMA’s E&M Revisions for 2021
Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
Partner at Doctors Management, LLC and President of NAMAS
This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.
The Centers for Medicare & Medicaid Services (CMS) is moving quickly on its strategies for outpatient office evaluation and management (E&M) services, targeted for implementation in 2021, and the American Medical Association (AMA) is working hard to try and keep up. Many who read the final rule for 2019 noted the E&M changes to be implemented in 2021 for the office/outpatient code set 99201-99215 and scoffed (myself included) that this would probably be much like ICD-10: an issue that gets kicked around a few years before final implementation.
Well, we (again, myself included) appear to be wrong, as AMA has released its own E&M coding rule changes, also to be introduced in 2021. The AMA is allowing comments for reconsideration until midnight Central Standard Time on Monday, March 25, 2019, and we once again encourage each of you to read the AMA publication and submit your feedback.
In a nutshell, the AMA’s changes are complementary to the CMS proposed changes to this code set, and they include:
- Deletion of 99201
- Removing history and exam as key components
- New definitions for the medical decision-making (MDM) components
- Modifying the definition of time-based services and what is included in time
- New guidelines sections within E&M
Deletion of 99201
The AMA has made the decision, based on utilization, to delete 99201 at this time. This code is rarely reported and therefore no longer needed. This actually makes sense, as most often we would only be reporting this code for encounters with essentially little to no documentation components.
Based on the current coding framework, the differences between the documentation requirements for a 99201 and a 99202 are that the Level 2 requires one review of systems (ROS) and one more organ system on an exam. There are those rare notes for which a provider may fail to include any ROS, but this is not typically the norm for most providers, as new and initial E&M services are usually their best documentation efforts.
Removing History and Exam As Key Components
AMA is changing the overall level of service scoring process by no longer requiring history and exam to be counted as key components. The change would then reflect that the history and exam should be medically appropriate. And here is the gray area. We already have this as an argumentative point of preventive guidelines: what is medically appropriate? If you are thinking ahead, you already know how this will be scrutinized. What would be the minimum history and exam that would be needed to indicate that the requirement for services being “medically appropriate” was met? Well, before we as coders and auditors arm ourselves with those boxing gloves, let’s consider why this change is being made. As of 2019, CMS has advised us that all components of the history may be documented and/or completed by someone other than the reported provider, as long as the provider is updating, supplementing, or approving the recorded chief complaint (CC), history of present illness (HPI), ROS, and past, family, and/or social history (PFSH). Therefore, if the whole history is no longer considered to be provider-level work, then there would be no need to continue to make it a documentation requirement.
That leads us to the elimination of an exam as a key component. Many coders and auditors have raised concerns of exam documentation looking the same from patient to patient, and day to day. The provider’s typical response is “but if that is the exam I do and those are the findings each time, how would you like me to say it differently?” And that makes perfect sense.
However, I believe we could all substantiate that there are providers clicking on that normal electronic medical record- (EMR)-crafted exam template for insertion into the documentation even when, just maybe, not every single element was actually part of the encounter. Forgive me, I tell this story often, but it is too appropriate not to share, and probably a good reason to support the elimination of exam as a key component:
I know a family practice provider in Arkansas with whom I have a great rapport and can be frank and honest. He is a really good doctor and wonderful to his community, even treating patients that approach him in a grocery store! However, while on-site we were reviewing an encounter of an 8-year-old with a wart. He documented an eight-point body system exam on the patient, and when we reviewed the note together, due to our candor, I asked him very politely if he actually did an eight-point body system exam, or was that just part of the template he chose?
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