Refinements continue for the evaluation and management (E/M) office-visit and outpatient documentation and coding reforms that took effect this year, and these include technical corrections updates to the Current Procedural Terminology (CPT®) code set published by the AMA that add clarity and answer lingering questions.

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The landmark E/M changes were developed by the AMA and adopted by the Centers for Medicare & Medicaid Services. Many physicians have reported having a lighter administrative burden and the CPT Editorial Panel issued the technical corrections in an effort to the make the changes easier to implement.

Looking to simplify E/M documentation and ease administrative burdens, the AMA assembled a joint work group in 2018 that represented the CPT Editorial Panel and the AMA/Specialty Society RVS Update Committee (RUC). The workgroup was led by Barbara Levy, MD, a former RUC chair, and Peter Hollmann, MD, former chair of the CPT Editorial Panel.

Drs. Levy and Hollmann participated in a recent AMA webinar explaining why the technical corrections were made and the questions they are designed to answer.

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“If you remember nothing else, remember the word ‘simplify,’” Dr. Hollmann, a geriatrician and chief medical officer of the Brown Medicine faculty medical group, said in the webinar.

He explained that simplification was the work group’s guiding principle, and its focus was on making “coding and documentation requirements easier to work with than they had previously been, and … to make sure we were capturing the right clinical information, but not making the documentation burdensome.”

Dr. Levy, a clinical professor of obstetrics and gynecology at the George Washington University School of Medicine & Health Sciences, noted the hours the work group put in and the extensive feedback it received during group calls that had some 300 people on the line.

“We really thought we had it all figured out, but what we thought was crystal clear turns out to be not so clear to other people,” she said. “The basis of these technical corrections is that we were listening to all of you as you were telling us that some things were not as clear as they could have been.”

A key to the office-visit E/M reforms was giving physicians a choice in whether their documentation is based on medical decision-making (MDM) or total time. This better recognized the work involved in non-face-to-face services such as care coordination. MDM criteria were also modified to move away from adding up tasks and toward focusing on managing a patient’s condition.

Dr. Levy noted, however, that an unintended consequence was developing for some practices that had apparently substituted a new E/M checklist for an old one.

“This was not our goal,” she said. “Our goal was not to remove a set of bullets for physical examination and history and add in a set of bullets for medical decision-making.”

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While the new guidelines removed ambiguous terms such as “mild” and clearly defined previously ambiguous concepts such as “acute or chronic illness with systemic symptoms,” the technical corrections inserted more clarity by specifically defining what is meant by the term “analyzed,” noting the difference between “major” and “minor” surgery and explaining what constitutes “discussion” between physicians or other health care professionals.

Discussion can include texts or instant messaging, Dr. Levy explained, adding that it can also be asynchronous, but it has to be more than sending chart notes or written exchanges included in progress notes.

“Discussion is about an interactive exchange,” she said. “The exchange has to be direct—not through intermediaries—and it has to impact the clinical care of the patient, which means it has to be timely enough that it's impacting the medical decision-making.”

The technical corrections also contain definitions for terms such as “unique test” and “combination of data elements.”

The changes to E/M documentation and coding only apply to services in the outpatient or office setting. Work has continued for inpatient, home care and nursing home E/M services and should go in effect in “CPT 2023,” Dr. Levy said.

The AMA has additional resources on implementing the E/M revisions, including step-by-step videos. Summaries of the revisions and explanations of how they will reduce administrative burdens are also available.

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