Simplified Outpatient Documentation and Coding toolkit



  • Jill Jin, MD, MPH, FACP
  • Jeannine Engel, MD, MACP
  • Kevin Hopkins, MD

See the toolkit PDF for complete author listing information.

This toolkit will help you reduce your documentation and coding workload by:

  • Describing the most recent billing and coding documentation guidelines
  • Illustrating workflow solutions for more efficient documentation
  • Providing examples of documentation to help educate physicians and their teams

Simplified Outpatient Documentation and Coding Toolkit

Reduce workload with recent updates to E/M coding and team documentation.

Simplified Outpatient Documentation and Coding Toolkit

Physicians and supporting team members in medical practices are experiencing burnout at an unsustainable rate. An unmanageable workload, in large part due to the electronic health record (EHR) documentation burden, contributes to physician burnout. Furthermore, a physician sitting at a computer performing the clerical task of data entry and note-taking is a low-value use of a high-dollar resource.

Physicians and advocacy groups have been asking to reduce regulatory requirements for less-meaningful work for the past decade. In recent years, there have been 2 major favorable changes in regulation to decrease documentation burden and redundancy for physicians during ambulatory visits:

  1. January 1, 2019 (PDF): allowing ancillary staff members to document certain parts of the clinical note that physicians can then review and verify, rather than independently re-document1
  2. January 1, 2021: changing level of service (LOS) codes to only depend on medical decision-making or time, not history or physical exam elements2

These changes recognized duplication in data collection and recording, helped clarify billing rules, and removed specialty-specific challenges created by the previous guidelines that had been in use for a quarter of a century. While it seemed intimidating to many physicians to understand yet another set of rules, most practicing clinicians agree that these changes "made sense" and made their lives easier because no substantial requirements were added, and many requirements were removed.

Learn how to optimize documentation and coding strategies in just 4 STEPS with the complete toolkit PDF.

Clinical vignette packet

Use this packet (PDF) of clinical vignettes from the STEPS Forward® Simplified Documentation and Coding toolkit during in-person training sessions.

Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.