New Billing Codes for Outpatient Office Visits

Changes to evaluation and management codes designed to reduce paperwork, improve patient care

Published in Dome - March/April 2021

Before Johns Hopkins internist Kim Peairs met with one of her patients last December, she made time to carefully review records from the patient’s recent hospitalization as well as material from her oncologist, rheumatologist, endocrinologist and hematologist.

After the visit, Peairs needed to contact those care providers to make sure they knew about the hospital stay along with her own findings and recommended next steps.

Such complex and time-consuming cases are common in her practice, often causing the physician to spend hours evaluating a patient’s condition and consulting with family members and specialists to determine the best options for care.

Until recently, neither Peairs nor Johns Hopkins Medicine (JHM) were compensated for such crucial evaluation and decision-making.

On Jan. 1, the American Medical Association implemented new requirements that represent a major shift in the way physicians and other providers can bill for patient care services. Part of the Centers for Medicare & Medicaid Services’ Patients Over Paperwork initiative, these changes affect some evaluation and management codes that providers use to document patient care. The changes are designed to reduce time spent on electronic records and paperwork, streamline regulations and focus more attention on health care outcomes.

The new guidelines affect some ambulatory codes for outpatient visits and represent the first major overhaul of that documentation process in 20 years, according to Jonathan Efron, senior vice president of JHM’s Office of Johns Hopkins Physicians.

Although nearly every department in the school of medicine is affected, he says, the departments of medicine, oncology, orthopaedics, Gyn/Ob, dermatology, psychiatry, surgery and pediatrics will feel the greatest impact. There will be no changes to documentation related to hospital care, consultations and some other services.

Previously, outpatient evaluation and management time was defined only as how long clinicians engage in face-to-face activities with the patient. Now it includes other work that occurs on the day of the patient encounter, such as reviewing tests to prepare for the visit; counseling or educating a patient or caregiver; reporting test results to a patient by phone; ordering medications, tests or procedures; and so-called “pajama time” documentation performed at home.

Peairs, who is clinical director for the Johns Hopkins general internal medicine practice at Green Spring Station, says the coding changes support the long-term relationship and continuum of care that she wants to provide for her patients.

“The new guidelines acknowledge that thinking about a patient’s problems and coming up with the differential diagnosis [careful consideration of possible causes for a set of symptoms] is valuable,” she says. “That’s the skill set that many providers bring to patient care, and now it’s being recognized.”

“I am thrilled with the changes,” says Johns Hopkins primary care physician Howard Levy. “For providers who are in fields that are more cerebral and less procedure oriented, it will improve fair compensation for the time we spend in the total care of the patients.”

The new guidelines underscore the effort to put more emphasis on the medical care and less on the lengthy notes to justify billing and surgeries — a change Levy says will improve the patient’s care.

Medical care documentation has been a challenge, says internist Maura McGuire, assistant dean for part-time faculty. “A lot of writing we’ve been doing is probably more for the insurance company than for the patient. We’re checking boxes, satisfying some rules about billing for the work, but we’re not really writing things that help us as physicians to care for our patient.

“The new rules allow us to write shorter notes that focus on reasoning and therapeutic plans. They will allow physicians and others to get credit for all the time they spend working on a patient’s problems on the day of a visit. This is a first step in a longer-term project to make documentation more provider- and patient-friendly.”

Levy says the change will also benefit patient safety. “The longer the note, the less likely it is to be read,” he says. “There’s a greater risk of some really important piece of information being missed because someone else who needed to see it didn’t notice it buried amongst all the billing attestation.”

Although the new guidelines also mean lowering reimbursements for some procedure-based services, such as X-rays and surgeries, they support Johns Hopkins’ ongoing efforts to increase professional satisfaction by reducing burdensome documentation and other bureaucratic inefficiencies, McGuire says.

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