We are going to now talk about the overview of the office E&M guidelines. Okay, so we know there were changes in 2021 and we should be used to these changes. We've been dealing with them for a while now, but I definitely want to make sure that everybody's kind of, you know, what is your knowledge base? So this takes me to the polling question. How confident do you feel you or your providers are in knowing the 2021 office E&M guidelines? Fairly confident now that they've been simplified. About the same as before, this coding stuff is hard. I just guess at the level I built, or thank goodness I have coders. Good, I like to see fairly confident. That one's ahead. That's good. That's good. The coding stuff's hard, yes. Thank goodness I have coders. I love it. All right, well, hopefully when I take you through this presentation, you'll get a little bit more insight and a little bit more confident, especially if you're a provider listening in and you're the one responsible for the level you submit and the diagnosis code you submit on the claim. You don't have a coder, you don't have any staff kind of filtering and looking at that information for you before it goes out. You definitely want to make sure that you understand those guidelines. So again, we're going to talk about the number and complexity of problems addressed, amount and complexity of data reviewed and analyzed, and the overall risk. So we're going to dive into the medical decision making, because that is what drives your level. And that's really what the change was, is decision making or total time, okay? We're going to look at the table at a glance, so we kind of know, okay, what we have, what is the scenario, and what would support a specific level of service. Talk about time billing in the office, and document, just overall documentation tips. All right, so guidelines. So when they made their changes in 2021, they were specific to 99201 through 205, and then 211 through 215. That is all the changes that were made were just specifically to those CPT codes. They deleted 99201. I don't think we were, you know, offended by that. We shouldn't be billing level ones as consultants. There are new guidelines, again, specific to all the other levels of services. And then, of course, we're going to go through the decision making table and times associated with the levels of services that you're billing. Keep in mind, time is not associated with 99211, because that is pretty well a nursing educational type visit. It is not necessarily for your physicians, your nurse practitioners, your PAs. They're going to be billing those higher levels of services, the level twos through fives. So when AMA came out with the guidelines, they pretty well stated history and examination is still required, but will not be part of the scoring to determine the level of decision making. The level will be based on decision making or total time. All right. And, again, we're going to break down the three components of the medical decision making table. But at the end of the day, medical necessity has to be in your documentation, okay? So really what they're saying is, what is the patient here for? What is the chief complaint? What is the reason you're seeing the patient for, okay? Your history and your examination need to be pertinent to that chief complaint, but we're no longer being county. You know, we don't have to have 10 review systems and eight organ system examination The focus is on what did you address and what is your plan for those conditions that you addressed? Are there any comorbidities, risk factors that impact how you take care of your patient? Okay? So that's the biggest, that's the key to not only the office, but the hospital changes that are taking place as well. And I know Dr. Littenberg's got a presentation on that this afternoon. So if you want to dive into all the official guidelines, we've got the AMA link here. So number and complexity of problems addressed. This is the kind of what I call the first component or column to your medical decision making. Okay? And I'm not going to read this slide word for word, but basically what they're saying is that make sure you are addressing it and you're not turfing it to someone else. Obviously, if your decision is to get some other specialty or service involved, that's a decision you're making. But if you are not managing or addressing that issue, then you really can't count it as problems addressed. And I see this sometimes, you know, I see when we do reviews, I see some documentation where they're pulling in a problem list and not their own assessment and plan. Well, a problem list typically in an electronic medical record is an ongoing, you know, list of everything that the patient's ever had. All right? So it could be, especially if you have an EMR where multiple specialties share that EMR, I mean, you could have 20 diagnosis codes on that problem list. The thing is, is if you are not managing that issue, you're not addressing that issue, those need to be taken off. So we never recommend a problem list. Just document in the assessment what you addressed and anything that impacted decision making. So what are reviewed? This is, you know, it can be records, it can be new tests that you ordered, anything you analyze, speaking to other providers outside of your group regarding the patient, things like that. So what is a test? A test is an image, a lab, psychometric, physiological data, okay? And it's one test defined by a CPT code is a unique test. So pretty well what that means is if you have a, if you get a CMP on a patient and you also get a liver panel on the patient, those are two unique tests. I get to count two of those, all right? The prior guidelines, it didn't matter if you ordered one lab or 80 labs, you only got one point, all right? So this, make sure when you guys are ordering tests, imaging, et cetera, that you're very specific as to what you're ordering because you get credit for multiple if it's defined by a unique CPT code. Combination of data elements. So what they're saying is a combination of different data elements. So for example, if you've got notes reviewed, test ordered, test reviewed, or independent historian, you can sum those up to equal the overall in the data component. Risk, the overall risk to the patient. This one we kind of, is I think the grayest of the medical decision-making table. So it says the probability and or consequences of an event, the assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor self-limited adverse effect may be low risk, okay? But here's the deal. It says definitions of risk are based upon the usual behavior and thought process of a physician or other qualified healthcare professional in the same specialty. Trained clinicians apply common language such as high, medium, low, or minimal risk. All right. So it's up to the provider to document specific risk factors involved, whether it's a procedure risk factor or a patient risk factor, meaning they require a higher level of sedation. They require an endoscopy to be done at the hospital because of their risk factors. Those are the things that need to be incorporated in your assessment and plan of care, okay? If you don't tell me, as an auditor, as an outsider, someone looking at your records, if you don't tell me what the risk is or what those risk factors are, then I may not be able to give you the, you know, the moderate risk or high risk, if you don't say. It says for the purpose of decision-making, level of risk is based upon consequences of the problem addressed at the encounter when appropriately treated. Risk also includes decision-making related to the need to initiate or forego further testing, treatment, and or hospitalization, okay? So again, I can't stress enough that we need to really clearly paint the picture of the patient's risk or the procedure risk or whatever the risk is involved with what you're doing, the workup that you're doing for that patient. So let's talk about procedure risks. So when this, you know, when the AMA first came out with the guidelines, we were like, oh my gosh, this is so gray, we don't even know what to do. So and I know Kathy and I kind of went back and forth, I think we even talked to Dr. Littenberg about this at one point, we're like, okay, what in the world is minor versus major? So in kind of an auditor's eye, I was thinking, I was assuming, we don't need, we shouldn't assume, but you know, when the guidelines are very gray, I was assuming that minor was probably a zero 10-day global surgery and a major procedure, major surgery was a 90-day global. Well, then the AMA cleared that up when they released in March of 2021, they released some updates to the office documentation guidelines and they say, nope, these terms are not defined by a surgical package, it's defined by the provider, okay? So it says, the classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the risk, okay? So again, you have to define as a provider, whether this procedure, surgery, et cetera, is minor or major to the patient and why, okay? The assumption is probably going to be minor if you don't put that information in there. Obviously, if they're having a major, major surgery and you're documenting those risks, but you know, there could be issue, you know, endoscopy, endoscopy is a big one, we, that's our main workup for patients and endoscopy could be considered minor for sure, but it also could be considered major for specific patients. Again, those patients that you're sending over to the hospital because they're too sick to scope them in the ASC, but you would have to document, this is a major procedure for this patient and this is why, okay? And my next talk, we're going to go through case studies and you'll see, we've got slides a visit for procedure with risk, without risk and major and all to do with endoscopy, okay? They also define surgery if it's elective or emergency, obviously, it's kind of self-explanatory emergency, like we need to do this now or soon as available. Elective means we're scheduling this out, you know, we're going to schedule this patient for surgery, you know, next month, okay, that is elective. And then, of course, we talked about risk factors. All right, so here is the medical decision-making table and, you know, we've got the codes to the left, which kind of represent the different levels of services, but you have to meet two out of the three criteria, okay? So you can't just say, oh, I have moderate for risk, it's a four. You have to have moderate risk and either moderate data or moderate for problem addressed because that will give you an overall moderate level decision-making, which supports a level four, okay, and whether that patient's new or established. So you have to have two of the three components. And that's been the same, that's been how we've done it before, but the verbiage of the decision-making table has changed, okay? So problems addressed, it's complexity of problems addressed. Is it a straightforward issue? I don't think we deal with straightforward issues. This is a minimal, self-limited, or minor problem. You know, if the patient comes in and they're seeing you in follow-up and they're like, I have no issues anymore, everything's resolved, and it's a quick five-minute visit and you tell them go home, call us if you need us, that's straightforward. But we deal more with chronic conditions. We deal with undiagnosed problems with uncertain prognosis. We deal with acute illnesses with systemic symptoms. We deal with chronic illnesses with mild exacerbation, progression, or side effects of treatment. And we also deal with chronic conditions with severe exacerbation, progression, or side effects of treatment, and then threat to life or bodily function, okay? So we deal with a lot of those patients. So when you are documenting this in your assessment and plan, for example, you get a lot of patients that have abnormal liver function tests, the abnormal LFTs, okay? You typically will do a workup on that patient. You'll get your own labs. You might get imaging. You might do, you know, whatever. You typically will do your own workup on that patient. That falls under moderate for problem address because it's an undiagnosed problem with uncertain prognosis. We don't know. This could be something simple as, you know, you're taking too much Tylenol to cut back to you have cirrhosis. You have, you know, your liver is not good, okay? So there's different levels of this, but you are doing your own type of workup for that patient. Abnormal CTs is another one. Actually, it can even be significant symptoms and issues the patients have that's been previously worked up. They send the patient to you and you got to do your own workup, okay? So a lot of patients can fall into that. Your IBD patients, Crohn's, ulcerative colitis, those are chronic illnesses. Is this a mild exacerbation progression or is this a severe exacerbation progression? And when I get into the ICD-10 talk this afternoon, so, so, so important to document if the patient has complications, issues, they're not at their baseline. We're changing medication. We are ordering tests on that patient, okay? So be specific, pull that information into your assessment and plan of care. So if you have a stable chronic condition, so GERD, okay? Patient comes in, they have GERD, we're refilling their PPI, that's low, that's low for problem address, but again, you have to have something else from one of the other categories to support that. All right, and I know, I apologize that this slide is, you know, there's a lot of information on it, but there is a lot of information when it comes to data and you have to meet certain categories to determine low, moderate, high. So it's basically minimal or none, it's basically none or I just reviewed a lab, that's it, okay? So you, you have either unique tests, review of records, we'll talk about this for a second. They have to be external records, not your own records, not your partner's records, not your nurse practitioner's records, it's external. So I reviewed records from a hospital, I reviewed records from the primary care, I reviewed records from cardiology, and you don't really have to put an essay in your note about them, you have to put the pertinence, okay? I reviewed PCP's notes, which showed blah, blah, blah, whatever's pertinent to the chief complaint, okay? Again, make sure you document any order of unique test or review, okay? One thing that I want to comment on, and AMA has addressed this and they have this in their guidelines, is that ordering a test is a review. We know that once we order it, we're going to review it, so we get credit for the order, but we're not going to get credit for the review, because that is the assumption is that it's going to be reviewed. Another thing to keep in mind is when we're talking about independent historian, that's a big one, okay? So what does that mean? Well, how many of you have encountered, you see a patient, they bring their spouse in, the patient is a poor historian, or they have a dementia, they have some sort of illness or issue that limits you to get a really good history from that patient. So you document, you can document this in your HPI, you can put it in your assessment plan, it doesn't matter where it is on your note, as long as you document it. But per spouse, patient is experiencing right upper quadrant pain at night, whatever, just anything that you gather from someone else other than the patient, document it, counts towards decision making. Another thing that the AMA said is if you, if you order, like if you do testing on a patient, okay, and you are billing separately for that test, you cannot count it towards decision making, because that's really considered double dipping, you're already getting RVUs for the review of that test, or for the interpretation, etc. So your capsules, your bravos, your manometries, things like that. So keep that in mind as well. Obviously, you're going to document it in your note if it's pertinent to the chief complaint, but we can't count that towards decision making. Risk, this is what we got for risk, minimal, low, moderate, high. Now there are some examples, and these are examples only, all right, minimal risk of morbidity, low risk. So basically, you know, if you don't tell me there's specific risks involved and what those risks are, the assumption is probably going to be low, but go into moderate risk, prescription drug management. How many of you write prescriptions all the time? One big thing that I want to comment on with prescriptions, when you document your assessment and plan, don't just say continue current medications, that tells me absolutely nothing. Document what prescription you write, the name and the dose, all right, because we know that PPI therapy, that's a big one, okay, that's probably the majority of our patients are on PPI therapy. Did you tell the patient to go get some over-the-counter Nexium, or are you writing the prescription for it? If you're writing the prescription for it, we need to know that, okay, because guess what, if we don't know it, the assumption is it's over-the-counter, which is probably low risk, okay, prescription drug management's a big one. All right, diagnostic endoscopy, okay, we consider that a minor surgery unless you tell me otherwise, and I've asked multiple physicians this question, and all of them immediately will say minor, okay, it's not a major surgery. However, how many of you do advanced procedures, you know, pancreatic necrosectomies, endoscopic submucosal dissections, those can definitely be considered major, but make sure you put that information into your assessment and plan. Diagnosis or treatment significantly limited by social determinants of health, okay, that is a huge one, and I know when Kathy went over the ICD-10 updates, we are getting more and more Z codes that represent social determinants, okay, food insecurity, housing insecurity, noncompliance, all kinds of social issues. There's so many diagnosis codes in that chapter, okay, so if you are trying to treat a patient, you're trying to get the patient to do, you know, take their medication correctly or follow up with their endoscopies appropriately, and they can't or they won't because they're noncompliant or whatever, it's important to put that information into your medical record, you know, and sometimes I think providers hesitate on that, it's like we don't want to tell on the patient, well, here's the thing, though, the patient, that patient that's, that is an alcoholic that has variceal bleeding, okay, that you tell them you need to have a scope, you need to be treated, they refuse, guess what, they end up in the ER once a month for a GI bleed, what's the diagnosis code? It's your diagnosis code. It's what they're seeing you for. We want to make sure that we're painting a good picture of quality of care, meaning we're trying to treat this patient but this patient's noncompliant, okay, so there's all kinds of social determinants of health that is in the moderate risk. High risk, if you look at the high risk table, it's pretty well hard to get high risk in the office, so drug therapy requiring intensive monitoring for toxicity, okay, this doesn't mean you say patient's on a high risk medication and be done with it, it means you are monitoring whether it's by labs, by imaging, you're monitoring something specific for toxicity because they're on this medication and you have to document that. Major surgery with identified risk factors, emergency major surgery, DNR, do not resuscitate, and decision for hospitalization, so again, thinking about those risk factors on an office patient, a patient that comes in a clinic, that's pretty well hard to get high risk, okay, it's the patient that you walk into the room and you're like, oh my gosh, you do not look good, or send them to the hospital, or they've got a lot of major issues. Time billing, okay, so we broke down the decision-making table, let's break down the time. Time is total time, okay, it's no longer face-to-face in the office, so a variety of activities that you spend on the day of the face-to-face visit, okay, it can't be the day before or the day after, it's the day of, and I know I've gotten the question, well, what if I typically review records the night before to, I'm sorry, that's just the policy, not my policy, that's just the guidelines, all right, so what can you count? Reviewing tests, performing the exam, the history, etc., ordering medications, tests, or procedures, actually documentation in your medical record, time you spend writing your note also counts, and this is just the definition by CPT of time, you know, of time documentation, so it just says includes face-to-face and non-face-to-face. Here are your time thresholds, all right, so no longer is it just 25 minutes, or 35 minutes, or 40 minutes, it's a range, okay, so here's what I say about time, you are not going to bill every patient by time, okay, because decision-making is going to support most of your visits, but take a patient that maybe is coming back in follow-up, you're doing a lot of reinforcement and, you know, talking to them about, you know, diet, and exercise, and things like that, but you're not really changing your plan of care, their condition is stable, but you're doing a lot of talking, okay, it's one of those, it's the patient that you can't get out of the room, it's like, oh boy, Sally's here, Sally, oh no, you know, I've seen providers, look at their schedule, and they're like, oh yeah, her, yep, I'm going to time that one, okay, so you've got to get paid for your time, but you're not going to time every single visit. So documentation tips, remember that HPI tells the story of the patient, whether new or established, put all pertinent information in this area, often data review is contained in this paragraph, okay, and that's okay, it's counted, doesn't matter where it's at, it's counted. The impression and plan should also contain what you are addressing, what you think it might be, differentials are very good, because we kind of, when you put your differentials in your impression and plan, that tells us what you're thinking it could be, okay, why you are ordering additional test procedures, instructions given to the patient, recommendations, list everything that you're currently managing, or conditions that play a role in the care of the patient, if not documented, no one knows what you did or what you're going to do, this is not just to support your level of service, but this is for medical necessity and pre-authorization of tests and procedures, and we'll talk about that this afternoon, I cannot stress medical necessity enough, even though history and exam don't factor into your visit in the office, you still have to document it, it still has to be pertinent, so for example, if a patient comes in with abdominal pain, you would expect to see an abdominal exam performed and documented. Another example, if the patient comes in with elevated transaminase, the social history specific to the drugs and alcohol should be documented as well as any family history, okay, so we got to make sense, it's got to be pertinent. All right, and I think that will take me to my next talk.

office E&M guidelines

2021

medical decision making

total time

documentation

social determinants of health