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:
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.
Mike and Mary
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