SGO Review Highlights New Changes to Outpatient Evaluation and Management Coding
The June 2021 edition of Gynecologic Oncology features, “Changes to outpatient evaluation and management coding: 2021 will be a better year” written by SGO members David O. Holtz, MD and Mark S. Shahin, MD.
The strategies outlined in the new review article include:
- Changes to outpatient Evaluation and Management coding for 2021 are explained.
- Outpatient visits are now based on either time or medical decision-making (MDM) only.
- The three elements of MDM will be the basis for most outpatient encounters.
- Frequently asked questions about the new system are addressed.
Drs Holtz and Shahin note that the new changes for Centers for Medicare and Medicaid services (CMS) “patients over paperwork” initiative that began in 2017 is now adopting coding changes as of January 1st, 2021. CMS has accessed several key areas that were in need of improvement specifically aimed at the evaluation of outpatient E/M visits. Some areas include visit time, past history, unrelated physical examinations and need for audits. CMS performed several surveys across various organizations of medical professionals to garner information on how to best improve the coding system and overall improve patient experience.
Dr. Holtz emphasizes how these changes will ultimately positive affect medical professionals. “Documentation for outpatient visits under the new 2021 E/M rules is significantly less burdensome. We will all have to focus our attention on how we document our medical decision making and the time we spend with the patient,” says Dr. Holtz.
The review also mentions the importance for decreasing physician stress as it relates to coding procedures. The cumbersome documentation will not only allow for refocus energies towards patients, but also decrease the amount and intensity of audits. “The new E/M rules let you spend much less time updating clinically unnecessary parts of the patients history and review of systems and lets you focus on what physicians are supposed to do: diagnose and manage a patient’s disease. CMS also states that the 2021 E/M rules should decrease the number of audits necessary for compliance, another source of stress for physicians,” explains Dr. Holtz.
Concluding their review, the authors include with some commonly asked questions and direct physicians to additional sources for education materials to familiarize themselves pertaining to the coding transition.