In 2021, when the Evaluation and Management guidelines were revised, the area with the most confusion was ultimately the amount and/or complexity of data to be reviewed and/or analyzed. Like with other components, misunderstandings with definitions and descriptions were at the root of the problem.
It is extremely important to read the full description and definitions provided by the AMA to interpret documentation as well as to have a good understanding of how clinical indicators contribute to the validity of the data reviewed and/or analyzed.
As we saw in the 1995 and 1997 Evaluation and Management guidelines, the requirement for reimbursement were tied to the combining of the patient’s history, examination of body areas and/or organ systems, and the final piece, medical decision-making.
This was for many years all we knew in order to capture reimbursement for the face to face encounters between physicians and their patients. In order to properly interpret the guidelines, we should look first at what we know regarding documentation standards and medical necessity.
The difference between documentation standards and medical necessity is important to understand. There are standards of documentation that will be required for certain types of services. Evaluation and Management services and surgical operative notes have commonly accepted standards for documentation that all physicians typically follow.
Then there is the medical necessity of service that will allow for third party insurance carriers to pay for a given service. Although physicians will always need to provide standardized documentation, payment will be made based on medical necessity.
According to CMS, medically necessity requires that the service or supply are:
1. Proper and necessary for the diagnosis or treatment of a patients condition.
2. Provided for the diagnosis, direct care, and treatment of a medical condition.
3. They meet the standards of good medical practice in the local area and are not mainly for the convenience of a patient or their physician.
With the preceding in mind we can see why it would be less of a burden on a physician or provider of service to allow them to decide what is medically appropriate for their area of expertise.
While it’s true that the problem you are addressing and the risk of complications and/or morbidity or mortality of patient management, will typically provide the highest level, the data section can be very integral to supporting a level as well.
When medical decision-making or time became the sole determining factors in reimbursement for Evaluation and Management services, the way the data categories were defined caused much confusion in comparison with how they were counted in the previous guidelines.
In conversation with physicians, we found that they were still counting components as they were previously able to with the 1995 and 1997 examination and history guidelines.
In the audits performed since 2021, what we have found is underutilized opportunities in the data components that can tell the story and help communicate medical necessity for many services. Even though the counting of examination elements, for instance is no longer being used to determine payment, this leads a physician or other qualified healthcare professional to gather additional information before diagnosing a patient definitively or before the risk of additional services are determined.
What kind of data do healthcare professionals analyze and/or review?
Review/order of each unique test
It’s important to note that reviewing a test previously ordered would be expected and not separately counted for the same test either at the same visit or an additional visit for the original test.
Ordering a test can be counted in the Evaluation and Management level only if it is not being reimbursed by a CPT®️ code separately.
Review of external notes from each unique source
Unique source definitions are given in the official guidelines: “a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity.”
Gathering data from an independent historian
This is someone who can give a confirmatory history that is required for the physician to treat the patient. A history that is from a reliable source will contribute to documentation of medical necessity.
Accurate documentation of why they are needed is also important such as a patient with Dementia or evidence that the patients developmental stage in life requires an independent historian.
Independent interpretation of a unique test
As defined in the guidelines, a unique test will be one that has its own unique CPT®️ code. To provide an independent interpretation, a physician will look at a test result they did not order or bill for separately and clearly document their own interpretation but this will not necessarily require a separate report. The more information provided, the clearer the medical necessity can be seen.
What we have been encouraging physicians to do is to think of the importance of the data section, as many times we discover missing documentation in this component that would have contributed to a higher level. Let’s look at some specialty examples that can help.
In a specialty, such as Orthopedics, we may not typically see enough data to use it as a component over problems addressed and risk, but it’s very common for patients to bring external tests performed elsewhere with them to their appointments. We encourage physicians to document well what their interpretation is for these encounters.
It is also common that orders are made for outside tests such as a CT or MRI in order to assess a fracture before moving to surgical treatment. It’s vital that physicians clearly document the reasons for these orders in their evaluation and Management documentation as validation for the test , thus justifying the cost, medical necessity and ensuring continuity of care.
We can look at the OBGYN specialty for examples of counting data correctly such as when the physician documents they reviewed a pap smear result, which was “normal “. Then you may see documentation of a patient stating their last result was “abnormal”. We would not credit a review unless we see clear documentation that the physician personally reviewed it and not simply that the patient stated the result.
While we want our physicians to feel less burdened, we also want them to be completely empowered to tell the full story, because it helps their patients get the services they need and contributes to accurate reimbursement. What we encourage physicians to focus on is accuracy to the best of their knowledge at the time of the service, and then the reimbursement will be justified based on the insurance criteria for payment.
We still need qualified professionals to interpret both payer rules and physician documentation to hold insurance companies accountable for their policies. We advise medical practices consider conducting audits because the data is still showing that many third-party payers are not following through with their own publicized guidelines. Keep subject matter experts close to your organization and you will have success.
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