How Might the New 2021 E/M Guideline Changes Impact Risk Adjustment?

by  Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content

While provider organizations are busy learning the new E/M guideline changes being implemented January 1, 2021, Medicare Advantage Organizations (MAOs) are contemplating how the documentation changes for these services may impact risk adjustment coding. To be clear, the new E/M guidelines only pertain to Office and Other Outpatient E/M Services (99202-99215) for now, but may, in coming years, be expanded to other subcategories of E/M services. Of the changes taking place, the following may be most enticing to providers and risky to RA coding, as they tend to reduce the documentation requirements and administrative burden associated with code selection.  

1. Because the history and exam will no longer be part of the E/M scoring process, providers will be able to document only those pieces of history (i.e., HPI, ROS, PFSH) and examination they feel is warranted for the patient's encounter on any given date. This is not only a risk adjustment issue, but also affects the potential impact of the documentation needed to support medical necessity. 
2. The provider may determine the level of service based on time (all time, not just face-to-face) instead of being limited to only counting face-to-face time when 50% or more was spent counseling and coordinating care.
3. Medical Decision Making (MDM) and Time will be used to determine the level of the E/M service reported, meaning that the history and examination components will no longer be evaluated for scoring purposes and providers may report only the details of a history or examination they feel is needed to determine proper patient care. 

Will There Be MEAT? 

Complete and accurate documentation is required to support services, medical necessity, and to safeguard against payment recovery. By now, most risk adjustment coders have heard, been trained on, or read articles that remind them to look for the MEAT within the patient encounter note to ensure complete and accurate documentation is present and can support the codes being reported. With the new E/M guideline changes we might ask ourselves if the documentation acronym MEAT will continue to be enough to support quality and high-specificity code assignment. As MEAT is a well-known acronym for risk adjustment coding, we will apply it here to identify how an MAO may prevent provider documentation issues moving into 2021:

Monitor (M) 

Begin the new year with early monitoring of contracted providers to see if and how they are documenting differently due to the E/M guideline changes. 

Evaluate (E) 

Carefully evaluate the reports from providers who are changing up how they document or are making obvious changes in their EHR templates to ensure the encounter notes continue to provide the level of detail required for proper code assignment. Are all conditions being monitored, evaluated, assessed/addressed, and treated being adequately documented to support an accurate ICD-10-CM code assignment? Is the patient’s history of long-term, permanent, or post-surgical conditions (e.g., amputated limb, long-term cancer therapy) being correctly documented annually? What about physical issues such as the patient’s BMI or ostomy status?  

Assess/Address (A) 

Has the provider decided to stop reporting a problem list? As these are often a great source of coding clarity, you may wish to determine how to address this change sooner, rather than later. Due to the level of E/M service being determined by MDM or Time, begin thinking about how your provider training may help providers support those diagnoses addressed or assessed during an encounter, including updates to the status of the chronic condition or one that has resolved, which may allow removal of that diagnosis from the risk adjustment process.  

Treat (T) 

Just as a physician might prescribe a medication or recommend a test for further diagnostic workup, MAOs may also recommend a treatment such as additional provider (or staff) education that includes a review of the new CPT E/M guidelines for 2021 and how they may impact the documentation and subsequently the codes assigned. Provider and coder education is an ongoing process and early intervention and monitoring is just as important to the success of an organization as it is to the health of a patient. 

References:

• AMA CPT 2021 E/M Coding Guideline Changes