After last year, we all needed a fresh start. A round of changes to evaluation and management coding guidelines from the Centers for Medicare and Medicaid Services might have health information management and clinical documentation improvement teams wishing for the “good old days” of 2020, however.
Under the new guidelines, physicians will still need to collect documentation detailing a patient’s medical history and whether a physical exam was performed, but these details won’t determine the code level of the visit. Instead, physicians can opt to determine code level based on the total time spent serving the patient or the amount of medical decision-making necessary during the visit.
Are More Coding Options Better?
While these changes passed down from CMS are designed to save time, they also add another layer of decision-making to an already complex process. For example, most payers allow coders to use guidelines from 1995, 1997, and now 2021 — but because picking the right one is paramount for maximizing revenue, coders will have to weigh each to identify the best outcome. In cases when a payer requires a specific guideline, incorrect coding could result in denials or missed opportunities for reimbursement.
Electronic health record templates will also need to be updated to ensure physicians capture the relevant information for coders. Any omission by physicians creates more work for CDI teams and another opportunity for missing information to slip through the cracks.
4 Steps for Transitioning to the 2021 Protocols
While the 2021 guidelines are here to stay, they don’t have to disrupt a hospital’s revenue cycle. To ensure a smooth transition to the new protocols, as well as an efficient and accurate approach to documentation and billing, HIM and CDI leaders should adopt these four transition strategies:
- Run a simulation of the new guidelines using existing charts.
Even if your coders are content to use guidelines from the past century, you could be missing out on revenue today. Take a handful of your existing charts and simulate billing payers with the 2021 guidelines to identify the right way forward.
- Audit the chart contents to ensure the necessary information is consistently captured.
With new guidelines, common templates such as those used in EHRs will need to be updated to ensure that the right details are captured during patient encounters. Analyze existing charts and note the absence of important information, and contact your EHR vendor to point out any discrepancies. Over-coding could occur due to providers not understanding the definitions (e.g., acute, chronic, or stable), and time can be misrepresented if providers do not realize that only the time the billing provider performed on the date of service is eligible.
- Audit the selected codes.
As coders contend with these new guidelines, resources such as computer-assisted coding software can help spot omissions or irregularities. Powered by natural language processing, this intuitive software can analyze, evaluate, and translate unstructured physician notes, distill information down to the necessary clinical facts, and ultimately identify the correct coding to use in countless scenarios.
Computer-assisted coding relieves physicians of the tremendous administrative burden of manually inputting this data and gleaning the insights from it while improving accuracy and decreasing denials. Additionally, where payers allow for selection of guidelines, CAC can determine which guideline to follow on a case-by-case basis.
- Create physician education.
When necessary, stress the importance of critical information capture and walk through the changes with your physicians. If the new guidelines are not understood or if the physician documentation does not consistently capture the right information, the impact will reduce revenue from missed coding or denials. Informed medical staff can easily make the difference between a painless transition and a coding nightmare.
If E&M is done accurately before and after the transition, the new guidelines shouldn’t have any negative effect on revenue cycles. Unfortunately, there are many cases in which physicians fail to capture the right information or coders fail to realize how the new guidelines affect coding opportunities.
Changing coder behavior represents the biggest challenge, to be sure. In order to minimize disruptions, adopt the above transition strategies and employ resources like CAC to make coders who might otherwise be overwhelmed with changes more accurate and productive.