UASI is on the front lines actively working with our clients to help them comply with the biggest change in evaluation and management (E/M) coding since 1997. The new office visit E/M code levels are assigned based on either medical decision making (MDM) or total time. The complex MDM rules make it really easy to under report office visit services. To accurately capture these services, you need to completely change how you document and count MDM.
For example, documenting the risk of complications and/or morbidity and mortality of patient management at the encounter (one of the three elements that determines the MDM level) presents some unique challenges as well as opportunities. For example, are your providers aware that over-the-counter medications are no longer automatically low risk? Providers may need to be educated to include a higher level of risk for OTC meds. UASI has tools to help with documenting MDM. The table below is an example of documentation tips we are gathering to help providers and coders adjust to the new rules.
Documentation of the Risk of Complications and/or Morbidity/Mortality
| DOCUMENTATION REQUIRED | DOCUMENTATION TIP EXAMPLE |
| Specifically identify any additional diagnostic testing and/or treatment ordered | Follow up labs ordered including CBC, BMP, HbA1C and CT chest without contrast |
| Identify any additions, deletions or revisions in prescription drug management | Discussed adding warfarin for Afib but due to patient’s history of GI bleed this was contraindicated |
| Document and specify any monitoring that will be necessary for drug therapy monitoring for toxicity | Will arrange for weekly blood test to monitor for pancytopenia during chemotherapy |
| Document any discussions/decisions regarding elective minor or major surgery. Include documentation of patient/procedure risk factors if performed | Patient referred to general surgery for I&D of pilonidal abscess. Discussed with patient the risk of recurrence, infection and bleeding |
| Identify any social determinants that may increase the risk in patient management | Provided patient with a list of prescription assistance programs due to unemployment and lack of insurance |
| Identify any co-morbid conditions that may affect the risk in patient management | Patient with community acquired pneumonia and underlying COPD |
| Document any discussions and/or decisions regarding hospitalization, DNR, termination of treatment, palliative or comfort care measures | Discussed with patient with stage IV CHF diagnosis and home hospice referral provided |
Contact UASI today with questions or to set up an exploratory call with our E/M experts at info@uasisolutions.com. UASI is evaluating the FY21 E/M codes for providers across the country and we are seeing some worrisome trends. Let us make sure your providers are on the right track.