Message From Your Region 8 Representatives | Michael Warner and Mary Wood

One of the responsibilities and pleasures of an AAPC NAB Board member is to visit chapters in our region.  We recently visited a chapter in Oakland. We started out sharing what NAB board members do and current action plans within the NAB committees that we serve.  We then presented information on how to prepare for 2021 CMS outpatient/office E/M changes.
We enjoyed meeting and interacting with members of the Oakland California AAPC Chapter. Members have interesting jobs, stories and coding backgrounds.
Though 2021 is a little over a year away, now is a good time to discuss CMS Final Rules of 2021. Starting 2021, History and Examination will no longer be key components of outpatient/office E/M documentation. Documentation obligations will focus on Medical Decision Making (MDM) only or Time only.
These changes raise many questions, such as “What do we do about the History?” Though starting 2021, CMS will no longer require outpatient E/M documentation for scoring/payment purposes, some type of History will need to be recorded to “paint a picture” of the patient for medico-legal and medical necessity purposes. How should we recommend History documentation to “tell the story” of the patient’s needs, concerns and experiences with health and disease?
Imagine reviewing the following 2021 outpatient E/M health record documentation:

Here is a picture of us with the Oakland AAPC Chapter Officers. We appreciate their hospitality and engagement.

Hx: none

Ex: none

MDM:

Diagnosis – R10.0 (Acute severe generalized abdominal pain)

Plan: CT abdomen, Metabolic comprehensive profile, CBC with differential

Yikes! What’s going on here? Did the patient fall off of a scaffolding and potentially rupture his spleen? Or, did he experience right lower abdominal pain that progressed to generalized pain? Without a History, it’s anyone’s guess and we shouldn’t be guessing as to what happened to the patient to prompt medical attention. Some type of History needs to be gathered and documented to “paint the picture” of the patient and “tell the story.”
How CMS 2021 Final Rules are implemented need to involve coders, auditors, compliance officers and practice managers. We believe AAPC members have a unique skill set to help navigate through new policy changes and serve as a resource for all members of the healthcare system.
 
Sincerely,
Mike and Mary

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Michael Warner, DO, CPC, CPCO, CPMA, AAPC Fellow, is an associate professor at Touro University California, president of non-profit Patient Advocacy Initiatives, alternate advisor on AMA RUC, and an AAPC National Advisory Board member. At Touro, he is conducting a series of research projects with the online tool www.PreHx.com to determine evidence-based best practices to accommodate a patient-authored medical history and improve data gathering flow.

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