A quarter century ago, the Centers for Medicare and Medicaid Services (CMS) rocked the medical establishment when it introduced its coding and documentation requirements for providers. A whole generation of physicians has never known a world without complex electronic medical records documentation. Significant revisions to CMS coding may soon change that.
CMS has revised the Current Procedural Terminology (CPT) codes for new and established patients in the ambulatory care setting. The changes, which go into effect Jan. 1, 2021, are intended to make electronic medical record documentation more clinically relevant and less burdensome for providers.
“With these changes, we’ll now have much less ‘box-checking’ for history, review of systems and physical exam and more of a patient-centered narrative focused on decision making within our medical records,” said Dr. Chris DeFlitch, vice president and chief medical information officer at Penn State Health. “It’s much better for communication between providers, and important for our care of patients. But it’s a pretty big mental conversion from the way we were taught to document for the past 30 years.”
DeFlitch explained that the revised CPT codes will allow CMS and other participating insurance providers — including Highmark — to assess billing levels based on just one section of coding: the complexity of medical decision-making.
“Providers will continue to note relevant history and the physical exam because it’s the right thing to do,” said DeFlitch. “But they won’t have to check all those boxes and add unnecessary, clinically irrelevant data for billing. What they will have to do is make sure that their thinking — medical decision making — is recorded correctly so their patient and the next provider will know what they are thinking.”
Knowing how to enter that information accurately carries a significant learning curve, said DeFlitch. “It’ll be a continuing learning process for physicians, advanced practice providers, and residents in documenting and connecting with their revenue integrity team to stay in lockstep with these coding changes.”
Mandatory training sessions for revenue integrity managers and other coders will be held on select days and times from Oct. 6 through Oct. 16. Penn State Health is pursuing continuing education credit for certified coders. Coders and revenue cycle managers may submit questions in advance of the training sessions to EM2021Questions@pennstatehealth.psu.edu.
ONLY staff who are in coder roles and coder management should register for the October training sessions. Please click on the link for one of the dates and times:
- Tuesday, Oct. 6, 2 p.m. Zoom webinar registration
- Thursday, Oct. 8, 8 a.m. Zoom webinar registration
- Thursday, Oct. 8, 2 p.m. Zoom webinar registration
- Tuesday, Oct. 13, 2 p.m. Zoom webinar registration
- Wednesday, Oct. 14, 8 a.m. Zoom webinar registration
- Wednesday, Oct. 14, 2 p.m. Zoom webinar registration
Following feedback from the October training sessions, information sessions will be offered to providers in November. Continuing medical education credit will be offered for the provider sessions.