Revenue Cycle Insider

Hint: If you’re going to use a template, check it for accuracy.

The 2021 changes to evaluation and management (E/M) medical decision making (MDM) brought more focus on patient-centered care, in part by adjusting the administrative burden required to determine the level of E/M provided.

In her HEALTHCON presentation “Teaching Providers Medical Decision Making for Coding,” Amanda Reikowsky, CPC, CRC, CPMA, CDEO, offered tips about how to continue to educate providers in their documentation of MDM, including tips on slight changes of verbiage that can underscore relevancy and establish medical necessity.  

Prioritize Quality of Information Over Volume

Even though the guidance for E/M leveling changed in 2021, providers may still be stuck in habits of yore, when the volume of information — complete history, including social, family, and medical, as well as a whole review of systems — was a major driver of leveling, especially for MDM.

Now, a helpful frame of reference may be to remember that a medical record is a legal document that has uses beyond just a record of a clinician and patient’s encounter, and thus, providers can focus on the quality of the information in the documentation, not the quantity, Reikowsky said.

 “I tell our providers it’s a trade-off, when they complain sometimes about how much documentation I’m asking for in the medical decision making of their assessment and plan area … you no longer have to include a medical history if it’s not relevant, you know you don’t have to do a review of systems — they’re not required to level your service at all,” she said. But, of course, sometimes that information should be discussed and recorded, especially in an encounter with a new patient.

For example, if a patient has a headache, the cause could be tied to something a provider might uncover with a review of systems, but there doesn’t have to be a formal review of systems built into a template, she said. Instead, providers can put that information into the history of present illness (HPI).

Suggest Subtle Shifts in Language and Know Your Tools

Similarly, Reikowsky recommended changing some verbiage when talking with providers, like switching to “presenting problem” instead of “chief complaint.” When providers change course to documenting the presenting problem, they’re establishing medical necessity, she said.

Think about documenting components of MDM for E/M as being driven by medical relevance, instead of just needing to document to determine a level of service.

This can apply to situations where established patients scheduling visits to establish care, too. If a patient is coming in to discuss test results, there may be a question about whether those test results could have been shared electronically or over the phone. But if they’re coming in for test results to follow up on a hypothyroid condition, then that’s the presenting problem — that’s the medical necessity being established for that visit, she said.

Templates can be a great tool and timesaver, but they can also be abused, Reikowsky said. She shared a story about coding for a surgeon who built a template for their average patient encounter that included heart and lungs in the exam portion, but somehow a tracheostomy scar had been built into the template and went unnoticed for years. They had to go back and addend the records to indicate that each patient did not have a tracheostomy scar, and that there had been an error in the template.

“You should only use templates when it makes sense to use templates, like maybe an annual wellness visit, your preventive visits, your well-woman exams, sports physicals — things where there’s a sequence of events, but it should look relatively blank. You should have the systems, the general areas you intend to examine,” she said.

Think of Assessment and Plan Like a Diary

The necessity of providing evidence to justify treatment decisions can be confusing and onerous. Reikowsky offered a simpler way for providers to think about documenting their assessments and treatment plans: Think of this section as if it were a diary of the day’s visit.

She said writing something like “I met this patient, and I was thinking about treating them with this anticoagulant for A. fib, but they do have that procedure coming up, and that would put them at risk during that upcoming surgery. So, actually, what I’m going to do is hold off on that medication for now” provides a more comprehensive picture of the assessment and treatment plan than “Patient has A. fib; we’re going to return 6 weeks after patient has a procedure.”

The latter example doesn’t include any of the thought process that happened and ultimately affected the MDM.

“You want to document all of that information all the way down to the signature!” she said.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC