Providers are currently stuck with outdated templates, leaving plenty of room for improvement.

I thought it might be appropriate to take a “four score and seven years ago” look across evaluation and management (E&M) services, looking at what we had, what we have, and what is still to come.

So, to begin, I will rewind the clock to pre-Johnny Depp-and-Amber-Heard-trial days, back to before the implementation of 2021 documentation guideline (DG) changes – and so, for most of you reading, this is your current world.

Your providers are, well, kind of stuck here. They are using templates in eClincalWorks Solution (eCW) or EPIC or CERNER that were created for archaic office-based DG demands that are no longer required. History of present illness (HPI), review of systems (ROS), past family social history (PFSH), and eight-point body system exams are all part of the equation, but you know that money, time, and perseverance were used to create those templates; I certainly understand that, but it is time to help our providers understand the power of documentation addressing the problems discussed during today’s encounter, just as they are brought up behind the closed door. This is the expectation of 2021 DG.

What we currently have within 2021 DG is a set of documentation guidelines that is for the most part well-defined, but in this auditor’s opinion, in no way a final product. There are important terms and gray areas left undefined that can cause carrier discrepancies and even all-out coder brawls inside organizations.

Take RX management, for example. Many Medicare Administrative Contractors (MACs) have defined RX management as the initiation, discontinuation, modification, or continuation of any prescription drug, but why did the American Medical Association (AMA) not include a definition to create alliance? However there was inclusion of a chronic problem definition that most clinicians disagree with, thinking that coders are crazy when we quote it. We need to ensure this 2021 DG is a living, breathing document, just as CPT is, and not a final document.

Where are we going with E&M services in 2023, as we look at the expansion of 2021 DG into other lines of E&M? I think personally, I am most relieved to see the incorporation of the rules in the ED space. The mixed carrier interpretation around new problems with additional workup leads to an unfair bias to a provider, who may be concerned with patient care and not the difference between a level 4 and 5. Our providers don’t always know the payor, and NAMAS has often been a third-party reviewer for carrier/provider disputes, noting that there is variance in carrier interpretation. How can we expect a provider to care for a patient in a lifesaving event and know the variation of the rules, and frankly, care about that? Moving beyond the need for such interpretations will be a welcome change.

I don’t believe that 2021 DG will solve all of the E&M problems within all of the types and variations of places of service we have. Especially if it is like 1995 and 1997 DG, and they are written but no further updates and rewrites are performed.

Let’s hope that these guidelines are better-maintained and updated.

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