2021 Office Visit Documentation Reforms Create Opportunities for New AI Documentation Solutions

As physicians continue to struggle with regulatory and administrative burdens, it’s exciting to see the advent of new AI-enabled ambient listening solutions* that can reduce the time physicians have to spend documenting and/or dictating notes.  This is especially true when considered in the context of the landmark 2021 office visit documentation and coding system overhaul. 

1995 and 1997 Documentation Guidelines

Prior to 2021, physicians were required to document patient visits utilizing the Centers for Medicare and Medicaid Services (CMS) 1995 or 1997 Documentation Guidelines for Evaluation and Management (E/M) Services in order to justify the selection of the correct E/M code for billing.  (For outpatient office visits, physicians had to choose between five levels of service codes for new patients (99201-99205) and five for established patients (99211-99215).)  The Current Procedural Terminology (CPT) descriptors for each level of E/M services recognized three key components that guided code selection: history, examination, and medical decision making.

As a result, physicians were forced to document the detailed elements of history, examination, and medical decision making for each visit.  In many cases, this required documenting a specific numeric requirement included in the description of an element (i.e. “An extended History of Present Illness (HPI) consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions.  Documentation guideline: The medical record should describe at least four elements of the present illness (HPI), or the status of at least three chronic or inactive conditions.”)  For years, this documentation system was identified by physicians as a leading cause of burnout.

2021 E/M Overhaul

On January 1, 2021, the first major overhaul in over twenty years to the American Medical Association’s (AMA) CPT E/M system went into effect.  The policy changes were years in the making and came as a result of work from both government and industry stakeholders to reduce burdens.  For outpatient office visit E/M services only, the 2021 changes:

·       Eliminated history and physical exam as elements for code selection.

·       Allowed physicians to choose to bill (and document) based solely on medical decision-making or time.

·       Changed medical decision-making criteria to move away from simply adding up tasks to instead focus on tasks that affect the management of a patient’s condition.

Compared to the previous 1995 and 1997 guidelines, these changes significantly reduce the amount of documentation required for code selection.

CMS + AMA = Government & Industry Reforms

Historically speaking, certain regulatory changes implemented by CMS only have a minor or isolated impact on the healthcare industry because they only impact Medicare providers or even a subset of Medicare providers (i.e. the Merit-based Incentive Payment System).  However, because these E/M changes were made by the AMA to its CPT code set and The Health Insurance Portability and Accountability Act (HIPAA) law requires commercial payers to use the most recent version of that code set, these changes applied to all payers.

Furthermore, even though the 2021 E/M overhaul only impacted services delivered in the outpatient office setting, in 2023 the overhaul was expanded to include services delivered in “other” settings, including: hospital inpatient, hospital observation, consultation, emergency department, nursing facility, home or residence services, and prolonged services. 

Impact on Physician Documentation Processes

With the addition of so many new regulatory requirements over the past few years, it’s easy to forget about changes such as these that actually removed regulatory requirements.  However, because these changes present an opportunity for physicians to retool their documentation systems and processes for the better, they could be worth revisiting, especially in the context of new technology solutions.

To watch the DC Update video about this topic, watch video.

 (*In October 2023, NextGen Healthcare, Inc. announced the availability of NextGen® Ambient Assist, an ambient listening solution that interprets patient-provider conversations in real time to summarize appointments and document care plans at unprecedented speeds.)