Is This the Year That the Medical Documentation Burden Will be Reduced for Clinicians?

Mar 30, 2021 | Blogs

The revised AMA code descriptors and guidelines for evaluation and management (E/M) services are the first significant revision of E/M reporting in more than 20 years. The new E/M office visit code-selection criteria removes complex counting systems for history, exam, and data that often varied by payer.

Instead, code selection components have been narrowed down to just two: medical decision-making related to the visit and coding by the total time (including nonpatient-facing activities on the day of service). The changes include:

  • Eliminating history and physical exams as elements for code selection
  • Clarifying and expanding medical decision-making (MDM) guidelines, including a new Level of MDM grid
  • Allowing clinicians to choose whether to code based on MDM or total time, which now includes non-face-to-face time by the clinician

The revision is a significant pivot in the way clinicians document care delivered during office visits. What’s more, the changes provide an opportunity to rethink clinic documentation, possibly reducing clinician burnout.

Redefining Medical Decision-Making

The updated MDM criteria are more clinically intuitive and more consistent among contractors and payers. Ambiguous terms and concepts, such as “acute or chronic illness with systemic symptoms,” are now clearly defined. The new criteria allow clinicians to document only information relevant to the clinical management of the patient. Other changes include:

  • Reduction in the number and complexity of problems addressed in the encounter
    • Clinicians can focus solely on the diagnosis being addressed during that visit
  • Reduction in the amount and complexity of data to be reviewed and analyzed
    • Clinicians no longer need to enter test data that is irrelevant or ancillary to the purpose of the visit, thereby reducing “note bloat”
  • Revision to risk of complications or morbidity of patient management
    • This can now include social determinants of health and reasons behind decisions not to admit a patient or intervene in some way
  • New and established patients use the exact same guidelines for MDM


Redefining Time

When selecting time as the basis for code selection, there are clearly defined ranges of minutes, including various ranges for new and established patients. Using time is now an option regardless of whether or not counseling and coordination of care predominate the visit.

Although MDM-related codes are expected to be used more often than time-related codes, the revised time codes can be used to document longer patient encounters that are low on the MDM scale but may involve extended periods of time, such as counseling or educating patients, family, or caregivers.

Other non-face-to-face activities that count toward time-related E/M codes include:

  • Reviewing tests in preparation for a patient’s visit
  • Reporting test results to a patient by phone
  • Ordering medications, tests, or procedures
  • After-hours documentation work performed at home

What Medical Coding Challenges are We Facing?

The new documentation is based on the traditional SOAP note—Subjective, Objective, Assessment, and Plan—the most common documentation method used by providers to input notes into patients’ medical records. SOAP allows providers to record and share information in a universal, systematic, and easy-to-read format. That’s great when those sharing the information are clinicians. But the 21st Century CURES Act, effective as of April 5, 2021, gives patients the right to full access to their healthcare records as well—including clinical notes—in an effort to help them make informed healthcare decisions and better manage their care.[1]

The questions are many: Will patients be able to understand standard medical terminology and acronyms used in SOAP notes? Or will it cause confusion? And since the coding revisions no longer require clinicians to enter lengthy patient-history information into the record, will patients find the lack of information, or gaps in information, concerning? Providing access to information in and of itself provides little value if that information isn’t understandable and usable.

How Augmedix’s AI Documentation Software Can Help Clinicians

Managing all of the details around the CPT code updates can be daunting. A great way to achieve compliance with less effort is by partnering with Augmedix for its virtual documentation products. Clinician practices can find immediate relief with a medical documentation specialist(MDS), which allows them to focus more on patients, see more patients, have more control over the pace of their work, and improve their work-life balance.

More than a virtual scribe or medical transcriptionist, Augmedix MDSs provide best-in-class medical documentation. For clinicians who would like to make changes, Augmedix MDSs can customize and manage those changes for them. For clinicians wishing to bill by time, Augmedix can insert time statements that meet documentation guidelines upon request by the clinician. For clinicians billing by MDM, Augmedix’s emphasis on ambient patient conversation ensures the capture of key details from the visit, in addition to clinician-verbalized medical reasoning, to enable delivery of complete, comprehensive notes.

With Augmedix Live, Augmedix also provides after-visit summaries for patients.