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Evaluation and Management Office/Clinic Visit Documentation Detour: A Bumpy Road Ahead (Medicare and Medicaid)

Change is frequently difficult; however, without it, progress is stifled.  As part of the Medicare Physician Fee Schedule Final Rule, in 2019 The Centers for Medicare and Medicaid Services (“CMS”) announced significant revisions are coming for reporting physician time and effort as it pertains to office / outpatient Evaluation and Management (“E/M”) visit services.  These changes are tied to the 2018 ‘Patients over Paperwork’ initiative and they bring the biggest shift in documentation and reporting visit services since the early 1990s.  Below we will discuss these changes and how to manage the necessary adjustments.

The COVID-19 public health emergency (“PHE”) took center stage in 2020.  As a result, CMS has more widely embraced telehealth, phone visits, and other distanced healthcare options in the name of public safety.  Despite the upheaval, changes impacting the new 2021 E/M guidelines for coding and reporting did become effective January 1, 2021, with very little fanfare.  Despite being overshadowed by the PHE, the new rules finalized and published by CMS   require physicians implement these important changes now.

Documentation and coding guidelines have not changed for E/M services in the past twenty-three (23) years.  To put this into perspective, if we consider a physician’s career averages thirty-five to forty (35-40) years, providers who began their career in 1992 could realistically be facing retirement soon and must learn yet another major change in how to document their most frequently billed services!  On November 1, 2018, CMS finalized bold proposals addressing provider burnout and their intent to provide clinicians immediate relief from excessive paperwork tied to outdated billing practices.  Healthcare professionals impacted by these processes will find this requires a significant shift in their methodology.  Though this change will have a major impact on almost every specialty practice in the United States, other than in coding and auditing circles, little attention has been given to the anticipated changes in documentation, code assignments, and the corresponding reimbursements for these commonly utilized codes.  Unless the provider organization has taken the initiative to prepare for these changes, providers may still be unaware of the change and impact this may have on their coding and documentation practices.

E/M visits are reimbursed less than many diagnostic and procedure codes; however, E/M codes are by far the most common charges submitted regardless of medical specialty or billing provider type.  According to CMS’ interim final rule (“IFR”) outlining changes through CY2020 and those planned for CY2021, in total, E/M visits of all types represent approximately 40% of allowed charges for physician fee schedule (“PFS”) services; and office/outpatient E/M visits, in particular, comprise approximately 20% of allowed charges for PFS.

A notable change includes reducing the impact of the history and examination component for office / outpatient E/M code selection.  This change allows the E/M level to be selected solely upon medical-decision-making or time.  Without being in the trenches of coding, billing, and auditing it can be difficult to grasp how these changes could significantly impact revenue, compliance, quality, and even patient care.  To some degree, every provider offering outpatient / office services will be affected.

What effects are we talking about exactly?  These new guidelines will have far-reaching effects in outpatient professional-fee clinics, and offices.  The new documentation rules establish new concepts and can be confusing to those who practice in more than the office / outpatient area, since the ‘old-school’ E/M documentation and coding logic will remain in place for all settings except outpatient clinics and office settings.  Now providers must learn a new way to document and value their services in their office / clinic but continue to apply old rules when delivering services outside of their office.  Imagine a  provider review during which both office / outpatient and inpatient services are scored for accuracy.  If the provider fails to remember to adjust their code selection based on the service area, it will result in decreased quality scores, provider frustration, possible missed revenue, additional staff time to make corrections and time spent on additional education efforts.

Since there are no guarantees other carriers will follow suit, it is almost certain to lead to some level of confusion for providers.  Potential hazards include providers over- or under-valuing their visits,  providing inadequate documentation, overcompensating to meet new guidelines – and all while trying to treat a patient and keep their care first and foremost.  CMS’ recognition of the need to decrease paperwork burdens and allow greater focus on patient care is to be commended.  However, if providers lack the time or resources to prepare for the change it could have the polar-opposite effect.

Information Highlights and What Next?

Stepping Back: Reducing the Documentation Burden after January 1, 2019.

In 2019, CMS released documentation guidelines indicating when relevant information is already documented in the medical record, practitioners may choose to focus their documentation on what has or has not changed since the last visit.  Providers need not re-record the defined list of required elements if there is evidence the practitioner reviewed the previous information and updated it as needed.

New and established patient office / outpatient E/M visits do not require the practitioner to re-document the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary.  The practitioner must document in the medical record that he or she reviewed and verified this information.

Stepping Forward: Reducing the Impact of History and Exam in 2021

Continuing CMS’ 2019 focus on providing guidelines to reduce physician burden, 2021 rules indicate ancillary staff may document relevant history and providers may include an examination pertinent to the current encounter; however, using the new “MDM-only method,” the history and exam would not be counted towards the level reported.  This will allow practitioners to focus their documentation on what has or has not changed since the last visit and code based on MDM or time.

Without diving into coding jargon, the new 2021 medical-decision-making methodology simply disperses the former, separate table of risk throughout the diagnosis and data portions, resulting in one table with three (3) columns instead of three (3) distinct tables for medical decision making.  This is a significant change from the prior table structure and will be used differently.

CMS will engage in further conversations with the public over the next two (2) years to further refine policies.

Other Changes to CMS Payment Rates and Logic in 2021

There was discussion CMS would finalize a single payment rate for E/M levels two through four (2-4) for office/outpatient visits: one rate for new patients and one rate for established patients; however, that currently appears to be on hold.  For 2021, CMS has removed the lowest level new patient visit code and slightly increased the values of the others; in addition, there will be new codes and requirements for related prolonged services.  All of the time requirements for each of the codes have been altered in the code definitions to accommodate billing on time, clarify what time can be counted and how it must be documented.

What should you do now to implement the change?

Start by reviewing the final rule at the link below.  Review or attend Medicare Administrative Contractors (“MAC”) education sessions or review their published information for providers.  Focus on how the medical-decision-making scoring and documentation requirements must appear in the record and what documentation may no longer be needed by reviewing the new MDM table using the American Medical Association link below.  Ensure coding and auditing staff have access to the appropriate resources and hold provider preparation meetings.  We have spoken to several providers who were unaware of the E/M changes described as of the writing of this article!

The 2021 E/M rules are now the new standard, changing how office/outpatient E/M code levels are reached and the corresponding reimbursement for these codes.

What Changes?

  • Logic and leveling will affect all medical specialties
  • Old E/M guidelines to remain in place for all other settings, e.g., inpatient visits
  • New codes and requirements for related prolonged services
  • Ancillary staff may document relevant patient history
  • Billing providers may include an examination pertinent to the current encounter
  • Documented history and examination of E/M office/outpatient visit not counted towards visit leveling
  • Code selection solely based on medical decision making or time
  • Disperses the table of risk throughout the diagnosis and data portions, resulting in one table with three (3) columns instead of three (3) distinct tables for medical decision making
  • CMS removes the lowest level new patient visit code and slightly increases values of the others

Challenges

  • Providers and coders will need to know when (and where) to use these new E/M guidelines versus old E/M guidelines
  • While the codes and definitions change in CPT text, it is unclear if all other payers will follow the new CMS scoring and leveling requirements
  • Preparing for major change during a health care crisis, e.g., orienting providers to the guidelines, providing staff education and additions / revisions to some documentation templates depending on how and which requirements will be followed across payors

For further discussion, questions, or information about our provider coding and documentation training services please Contact Us Online or give our coding compliance experts a call at 303-801-0111.

About Pinnacle:

Pinnacle Integrated Coding Solutions (PICS) offers experienced and knowledgeable coding resources with broad experience in revenue cycle and reimbursement compliance.  Our team serves clients nationwide with coding reviews, education & training services for providers and coders, specialized coding services, and much more.  Our coders, auditors and leadership are trusted advisors to hospitals, physician practices, ambulatory surgery centers and health systems looking to improve their business performance, reduce their risk, and enhance compliance.

Pinnacle Enterprise Risk Consulting Services (PERCS) provides compliance, litigation support, internal audit, medical necessity review, revenue cycle improvement and Independent Review Organization (IRO) services.

References:

Complete 2018 Final Rule

https://www.govinfo.gov/content/pkg/FR-2018-11-23/pdf/2018-24170.pdf

Most recent IFR from CMS (for 42 CFR parts 410, 414, 415, 423, 424, and 425)

https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf

American Medical Association overview

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

BY:

Autumn Hull, CPMA, CPC, CEMC, CPAR

Supervisor of Professional Audit Services

Kelly Loya, CPhT, CPC-I, CHC, CRMA

Associate Partner

Pinnacle will be attending and exhibiting at Colorado Hospital Association’s 2019 Annual Meeting

Six Things Every Rural Hospital CEO Must Do: Part Five

Rural hospitals are closing at a record pace, and many of the reasons why could have been avoided.

 

By Robert Thorn, MBA, FACHE

Director, Pinnacle Healthcare Consulting

 

Last week, in Part Four of this six-part series on “Six Things Every Rural Hospital CEO Must Do,” we examined Topic #4, Telehealth.  This week, in Part Five, we will look at Telepharmacy and how it can become a routine and relied-upon part of rural healthcare.

Part Five: Telepharmacy

As I travel to rural communities and learn more about how they operate, one constant challenge I see is related to in-house pharmacies for Critical Access Hospitals (CAHs).  Many of these CAHs are too small to justify a pharmacist on staff; rather, dispensing of medications is often left to one or two well-trusted nurses.  These nurses are sometimes supported by a traveling pharmacist or retail pharmacist in the community, who ensures medication inventories are monitored and that everything is properly accounted for.  However, while these pharmacists provide a valuable and much needed service to their community hospitals, the number of rural pharmacists is declining.  Consequently, many of them do not consult with physicians prospectively and review and verify orders prior to dispensing, as they commonly do in larger hospitals that have pharmacists in-house.

Just as primary care physicians may send EKGs to a cardiologist or images to a radiologist, medication orders can be securely sent electronically to a remotely-located clinical pharmacist for review.  And, the improvement in coordination of care can be felt very early on.  Specifically, when one particular telepharmacy program was started by a regional tertiary medical center with five Critical Access Hospitals, every time a new hospital was brought on-line, there was a pharmacist-initiated intervention within the first two weeks.  These were all good, quality rural hospitals with quality physicians and staff.  However, when orders were passed in front of the knowing eyes of a clinical pharmacist for review, in real-time prior to dispensing, things were seen that may have been previously missed.  And, once you go to that level of care, you will wonder why you had not done it sooner (and possibly, shudder…).  Besides patient safety, the improvements you will see with the involvement of a clinical pharmacist in real-time consultations, review and verification of orders, include the possibility of less waste from use of lesser-effective medications.

If you would like to discuss how to set up a telepharmacy program in your hospital, please let me know and I would be glad to speak with you.  I may be reached at rthorn@askphc.com.

 

In next week’s edition of this six-part series, we will explore our final subject, topic #6 of the “Six Things Every Rural Hospital CEO Must Do.”  I hope you will join me.  Should you have any questions in the meantime, please feel free to contact me at rthorn@askphc.com or (720) 598-1443.

 

Pinnacle will be attending and speaking at the 38th AHIA Annual Conference. Kelly Loya will be presenting on Billing Utilization Data Analysis for Focused Investigations

Six Things Every Rural Hospital CEO Must Do: Part Four

Rural hospitals are closing at a record pace, and many of the reasons why could have been avoided.

 

By Robert Thorn, MBA, FACHE

Director, Pinnacle Healthcare Consulting

 

Last week, in Part Three of this six-part series on “Six Things Every Rural Hospital CEO Must Do,” we examined Topic #3, Strategic Planning.  This week, in Part Four, we will look at Telehealth, how it has become more commonplace due to the COVID-19 pandemic, and how it can remain a routine and relied-upon part of rural healthcare.

Part Four: Telehealth

With the introduction of COVID-19 into our world, providers have been scrambling to develop alternatives to people coming into the office to be seen.  The government cleared a lot of hurdles to allow providers and patients to see one another via video platforms.  Medicare even changed its restrictions for reimbursement; state licensure has at least been temporarily waived, as well.  Regardless of whether these changes are temporary or permanent, having a solid plan to provide safe alternatives for patients and doctors to use in getting together will be required to navigate the “new normal.”  Moving forward, it is the patients’ expectation that providers offer convenient, effective and secure telehealth options. So, where do you start?

In my previous post, Part Two, “Physician Demand Analysis,” I wrote about the need to assess your medical community and identify where there may be opportunities for an increased presence of specialists.  While there can be an argument made that nothing is better than for a doctor and a patient to be in the same room at the same time, there is also an argument that can be made as to whether having a doctor and a patient in the same room is always a good idea.  Besides the COVID-19 pandemic, patients living in rural communities have other factors to consider, such as driving long distances, sometimes in questionable weather, and often having multiple appointments requiring multiple trips.  Therefore, if you have not done so already, it is time to assess your community’s medical staffing needs; and, based on these needs, determine which physician specialties are needed, and can they be supported through a virtual presence?  Do they need a face-to-face exam, or will data (medical test results, remote patient monitoring, images, etc.) prove to be more meaningful to the physician? Furthermore, where do opportunities lie for recurring treatments, such as dialysis?  Can they be coordinated and safely offered in a setting previously considered unacceptable because the specialist is not routinely physically present?  Telehealth has opened the door for rural hospitals to provide diagnostic and therapeutic services that could both benefit the patient through increased local access, and the hospital through an ability to offer services and retain the revenues that were going to another community.  It can also help position the hospital for value-based models of care, allowing the hospital to better manage its risk by addressing chronic conditions proactively and cost-effectively, rather than reactively and costly.  After all, telehealth is more than two-way video that has come into the limelight as a result of the COVID-19 pandemic.  It is yet another tool providing valuable information that providers can use to assess, treat and manage care, driving a more responsive approach and, in many cases, a higher quality outcome for the patient.  If you have not considered telehealth as a viable option for you community, or if the specialists to whom your physicians refer patients have not, please contact me and I would be glad to discuss options with you.  I may be reached at rthorn@askphc.com.

In next week’s edition of this six-part series, we will explore Topic #5 of the “Six Things Every Rural Hospital CEO Must Do.”  I hope you will join me.  Should you have any questions in the meantime, please feel free to contact me at rthorn@askphc.com or (720) 598-1443.

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Medicare Physician Fee Schedule Changes – What Now?

By Allison Carty, JD, MBA

Director, Pinnacle Healthcare Consulting

 

Medicare Physician Fee Schedule Changes – What Now?

 

An Introduction…

 

As many in healthcare have been tracking, the Centers for Medicare & Medicaid Services (“CMS”) released the calendar year 2021 Medicare Physician Fee Schedule (“MPFS”) which contained key changes to evaluation and management (“E&M”) coding and documentation requirements.  These changes will have substantial compliance, coding and documentation, reimbursement, and compensation plan administration implications, including a notable impact on organizations that compensate physicians on a productivity model.  The question looms: how should organizations respond to the new rule?  How is your organization responding?

 

Preliminary Observations and Options

 

Based on the changes in the fee schedule, a few key observations are apparent:

Preliminary Observations and Options

 

Based on the changes in the fee schedule, a few key observations are apparent:

 

  • Physicians who are compensated on a per work relative value unit (“work RVU”) model may earn higher or lower compensation under the 2021 MPFS;
  • Specifically, physicians billing a notable amount of E&M codes on a work RVU model may meet their production threshold more quickly than in prior years;
  • Hospitals/employers may receive less reimbursement and thus greater losses unless changes are made to physician agreements (i.e., particularly with rising physician compensation); and,
  • Due to increased amounts of work RVUs under the new MPFS, physician compensation per work RVU may decrease if compensation remains similar to prior years.

 

Because of these dynamics, some hospitals are considering adjustments to their physician arrangements to mitigate losses resulting from an environment characterized by rising physician compensation (i.e., due to increased work RVUs under the new MPFS) versus less incremental reimbursement.  Specifically, some hospitals are considering adjustments to physician compensation terms including increases in work RVU production thresholds and/or decreases in compensation per work RVU conversion rates. These same entities might also consider alternative forms of compensation to support specialists through affiliation agreements.

 

In addition to these types of contractual changes, many hospitals and medical groups are in the process of determining a response for purposes of physician compensation plan administration.  For instance, many organizations are considering the following options for purposes of administering their contracts:

 

  • Retaining 2020 work RVU values;
  • Implementing 2021 work RVU values and absorbing the impact of the changes to reimbursement;
  • Implementing the 2021 work RVU values but adjusting the compensation per work RVU rate to offset the impact of the changes;
  • Moving away from a work RVU structure; or
  • Awaiting further legislation.

 

Furthermore, some entities plan to make any changes quickly whereas others have yet to enter the planning phase to address the updates.  While most organizations have yet to make a definitive plan for how they will move forward, many are working to quantify the size of the impact, evaluate alternatives, or are seeking recommendations from internal or outside resources (legal counsel/consultants).

 

How is Pinnacle Analyzing the Changes?

 

Impact Assessment

Pinnacle is currently working with several clients to assess the impact of the MPFS changes and to make recommendations for relevant physician compensation plans.  These analyses review the impact to both work RVUs and reimbursement based on the specialties and case mix of our individual clients.

 

A Note on Benchmark Data

In addition to the challenges inherent in the MPFS updates, these changes come on the heels of the COVID-19 pandemic, which is another factor that will undoubtedly have a material effect on benchmark data for physician compensation and production.  Using benchmark data without consideration of the impact of the MPFS changes may result in compensation that runs afoul of fair market value and/or commercial reasonableness requirements.

 

Industry Survey

Given the sweeping implications of the MPFS updates, Pinnacle is conducting a survey amongst our clients and contacts to determine how and when organizations plan to address these MPFS changes.  Results from the survey are still incoming; however, Pinnacle will publish an article which summarizes our findings and associated key takeaways.

 

What’s the Current Takeaway?

 

Think about what the MPFS changes mean for your physician contracts.  Pinnacle will continue to monitor regulatory updates and will publish our survey results in an upcoming article.  Please check back to review survey results and additional tools for assessing the impact to your organization.

Pinnacle is proud to sponsor and Curtis Bernstein will be presenting at the ABA Physicians Legal Issues Conference

Six Things Every Rural Hospital CEO Must Do: Part Three

By Robert Thorn, MBA, FACHE

 

Director, Pinnacle Healthcare Consulting

 

Last week, in Part Two of this six-part series on “Six Things Every Rural Hospital CEO Must Do,” we examined Topic #2, Physician Demand Analysis.  This week, in Part Three, we will look at the need for a Strategic Plan, and why it is an important tool every rural hospital CEO should leverage.

 

Part Three: Strategic Planning

 

One of the most common practices I see in rural hospitals is using the budget as the organization’s strategic plan, whether intentionally or by default.  However, for a budget to be truly effective, it should be based on strategies, which drive goals and tactics, and the resources to support them.  Planning assumptions, or premises, should be reviewed at least annually to drive each year’s budgets; and, if not annually, at least every two years a rural hospital should undergo a formal strategic planning process.  In today’s rapidly changing healthcare environment, other than planning for major capital expenditures, strategic planning windows of more than two years could result in missed opportunities, changes in the market and the need to respond to new payment models.  As an interim CEO who prepares an organization for its permanent leader, it is my job to walk the new leader, board, medical staff leaders and others through a post-leadership transition strategic planning process.  It serves as an excellent opportunity for the new CEO to get an overview of both internal and external factors, how well the organization is positioning itself and performing, and to confirm the strategies already in place are sound.  When a budget drives strategy, this opportunity does not exist.

Regardless of whether your organization has conducted a strategic planning process in the past, has used the budgeting process to drive strategies, or is transitioning to a new leader, Pinnacle Healthcare Consulting can provide a strategic planning solution that both drives your budget as well as fits within it.  If you would like to discuss options, please let me know and I would be glad to speak with you.  I may be reached at rthorn@askphc.com.

In next week’s edition of this six-part series, we will explore topic #4 of the “Six Things Every Rural Hospital CEO Must Do.”  I hope you will join me.  Should you have any questions in the meantime, please feel free to contact me at rthorn@askphc.org or (720) 598-1443.