By Doreen DeGroff | Oct 23, 2020
On January 1st, 2021, the American Medical Association (AMA) is set to roll out a new set of Evaluation and Management guidelines. This is part of the CMS Paperwork Over Patients Act to reduce the administrative burden and ambiguity related to medical documentation and coding. Here, we’ll lay out our time-tested approach to addressing coding changes to help you hit the ground running with these changes when the New Year arrives.
Analyze First, System Last
Typically, the first question we hear from EHR clients is “How is the system going to handle this?” While this is certainly a valid question, the first question step should be to define a process for implementing these changes. The approach we follow for our EHR solution at CereCore, as well as for our clients, is Analyze, Policy, Educate, and System (APES). While this approach is internally developed, it is a time-tested method that our team has found to make the overall process easier and more effective.
A – Analyze
This three-step process helps organize the process and define the impacts of some of the coding changes.
For level 2 through 5 visits, you need to choose between using the current framework, Medical Decision Making (MDM), or time:
How do some of these changes impact the documentation workflow? If the decision is to modify documentation recorded during the visit, can the provider easily access this information in other parts of the record for reference during the visit? Providers will no longer be required to reenter information recorded by office ancillary staff and/or the patient. It will be important that this information is accessible for the provider's review and perhaps even melded into the documentation and they can review and verify.
Practitioners also need to look at the information that may no longer be required for applying the correct visit code but may be needed for other regulatory and quality initiatives. Finding the right balance to document the minimum necessary to meet all criteria may be the toughest part in applying these new changes.
P – Policy
Here is where you take what you learned during your analysis and define what this means to your organization. How will you apply the guidelines within your provider practices and what Policies and Procedures, Bylaws and other items need to be updated?
Based on your business decisions, make the required updates.
E – Educate (and collaborate)
Education of your stakeholders and users is not only a continuous process but also a collaborative one, especially as it relates to implementing changes to business processes.
S – System
Once you understand the new regulation, how it impacts your facility, and what policy and procedure is best for compliance, then it is time to look at the system and ensure it can support your decisions in the most efficient, user-friendly manner.
The CMS Patients over Paperwork Act will continue to evolve after the next phase in the new 2021 year. I hope the above tips are beneficial in defining a process that supports your facility through these changes and beyond.
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MEDITECH Senior Product Director, CereCore
MEDITECH Senior Product Director, CereCore
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