Unless CMS announces a last-minute delay because of a huge surge in COVID-19 cases, which is improbable, physicians and advanced practice providers (APPs) on Jan. 1 will shift to new documentation guidelines for office/outpatient services, and coders will follow their lead. The new documentation guidelines are a bit more relaxed than the checkbox-driven templates in electronic health records and rely more on a physician’s cognitive investment in patients, experts say. But templates may not have been updated for the new reality, and underdocumentation is a concern.
CMS in the 2020 Medicare Physician Fee Schedule regulation aligned evaluation and management (E/M) coding with changes adopted by the American Medical Association (AMA) CPT Editorial Panel for office/outpatient visits, with a 2021 effective date. Instead of the 1995 and 1997 Medicare documentation guidelines, physicians and other practitioners will use a new set of guidelines for office and outpatient codes. The AMA documentation guidelines are baked into the CPT codes, which means they apply to all payers. The E/M guidelines were incorporated into the CPT manual, and they include a new table for the elements of medical decision-making.