BC Advantage - 2020 Issue 10

Focus Providers on Clinically Relevant History and Exam, and Concise Medical Decision Making

It's fair to say the 2021 changes to the E/M documentation guidelines ease the documentation burden on the rendering provider for certain aspects of the note. These welcome changes give more heft to the clinical relevance of the patient's case and the provider's treatment, rather than the legacy documentation guidelines' focus on counting certain elements of history and examination.But nobody expects payers to stop auditing these claims, and recoupment efforts are likely to continue – or even increase based on how the guidelines are interpreted.While it is commonly believed the new guidelines are “easier” for the...

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