OPINION

E/M Coding Since the 2021 Changes: It Really Is Better

 

There's more work to be done, but the new rules simplified documentation and coding criteria and should result in increased revenue.

Fam Pract Manag. 2022 Jan-Feb;29(1):7-8.

Author disclosure: no relevant financial relationships.

Change is difficult, regardless of how much it's needed. Learning a new system for coding office/outpatient evaluation and management (E/M) visits last year was no exception.1

“This is too good to be true. There must be a catch,” I said to myself early on, fearing audits and wondering if it was truly safe to leave off the documentation of a few systems that I briefly reviewed but were not essential for my medical decision making.

Due to these lingering apprehensions, my notes largely looked the same in the first few months of the new coding guidelines. But with practice, I am gradually trimming them and coding with confidence. That's just one example of how the E/M rule changes have improved my professional life. As the months have gone on, it has become increasingly clear to me: It really is better.

AN END TO “NOTE BLOAT”

Many physicians believe the E/M changes were about billing, not patient care. But the changes were in line with the Centers for Medicare & Medicaid Services' “Patients Over Paperwork” initiative,2 and in my experience there have been some real advantages in terms of documentation.

With more robust systems for managing information, it was unnecessary to require physicians to include every bit of medical history in each note. Such “note bloat” could even put patients at risk by burying pertinent information. The guidelines no longer require quantifiable elements but do require a medically appropriate history and exam. That's reasonable. Now we can make our notes more meaningful, and our documentation can simply convey the care provided.

Some physicians have suggested there's no need for coding and documentation requirements at all. But rules of some type are here to stay. Beyond communicating a brief summary of patient encounters, there is an ongoing need to prevent fraud, waste, and abuse. Still, having notes that reflect the care provided rather than boxes checked is a burden lifted.

SIMPLIFIED CODING CRITERIA

It's easy to pick apart

ABOUT THE AUTHOR

Dr. Church is a family physician practicing in Hiawassee, Ga. He is core faculty for the Northeast Georgia Medical Center Family Medicine residency program and is the American Academy of Family Physicians' advisor to the American Medical Association's CPT Editorial Panel.

Author disclosure: no relevant financial relationships.

References

show all references

1. Church SL, Adamson M. E/M changes for 2021: The beginning, not the end. Fam Pract Manag. 2021:28(1):8–10....

2. Burden Reduction — Patients Over Paperwork. Centers for Medicare & Medicaid Services. Accessed Nov. 22, 2021. https://www.cms.gov/

3. Millette KW. Countdown to the E/M coding changes. Fam Pract Manag. 2020;27(5):29–36.

4. How the E/M code RVU increases could affect family physicians’ pay. FPM Getting Paid blog. Jan. 18, 2021. Accessed Nov. 8, 2021. https://www.aafp.org/

5. Skeldon S. Why you may not have seen a pay increase from the 2021 E/M code revaluation. FPM Getting Paid blog. July 21, 2021. Accessed Nov. 8, 2021. https://www.aafp.org/

6. Errata and technical corrections — CPT 2021. American Medical Association. Sept. 3, 2021. Accessed Nov. 8, 2021. https://www.ama-assn.org/

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