2021 E/M Coding & Documentation Changes: FAQs

Why is my CC being deleted when I layer a template?

The Chief Complaint (CC) is not being deleted or replaced. However, when a new template is layered, additional CC/HPIs are coupled together and added to the Encounter. A toggle located in the HPI section of the Encounter is used to move forward and backward through all CC/HPIs that have been added. The ROS section remains the same throughout the layering so that there is one comprehensive Review of Systems attached to the Visit.

In the animation below, you will see Sore Throat being entered as the first CC, and then Ear Pain layered on top of it. You will also see the toggle count increase to two and the use of the forward and backward arrows.

Why is my template name appearing in the Plan section?

The template name is being used as a "header" to separate the Plan for each template applied to the Encounter Note. The providers are able to delete this or modify the name, and it will not impact their Note prior to saving. 

If a practice chooses, they can disable this by deselecting the show template name as header to plan and patient instructions checkbox located in Global Preferences (Admin tab > Global Preferences > Special tab > Medical tab).

Who is responsible for entering the Independent Historian?

The Independent Historian can be added by anyone within the Visit Info tab of the patient's encounter.

Will OP "flip a switch" on 12/31/2020 to track coding differently?

OP has every intention of getting this update to our practices sometime by mid-December so you can start to see what this will look like. The legacy coding decision support will still exist on the alternate tab for you to use until January 1st.

Can APRN's use Time Based Coding? Or is that only for MD's?

Anyone who does clinical work and is considered a provider that can independently bill an E/M visit can use time: NPs, PAs, and physicians.

How would you know if a provider finishes a note the day after the appointment?

The audit trail in the EHR can track when work is done and who is logged in doing it.

Does the nurses time spent with the patient count?

The time the nurse spent with a patient does not count in the calculation of Time Tracking. The Billing provider's clinical time is the only thing that counts if you are using time.

How does it affect the encounter level if the Problem list is not reviewed by the physician?

"Reviewing" a problem list has no relevance on E/M coding level regardless of who does that work. It has to be a problem that is ADDRESSED in the assessment/plan of the note and that by default, must be the provider.

Does the note need to be finalized on same day or just the essential documentation to demonstrate risk?

You can do it the next day but you can't count any of the clinical work that is performed after midnight of the day of the visit. Some people may choose to delay if they feel like there may be additional work that will contribute to the E/M level that may happen after they leave the office for the day.

If the provider who takes an after-hours call is not the same provider in our practice who saw the patient in clinic, is that time able to be included in the total time of care?

Per the AAP, yes, so long as the time is spent on the same day, it is cumulative with the same physician and same physicians in the same group practice and the same specialty. How you bill it out (ie, under which physician) is an internal decision and nothing CPT addresses. Each physician should clearly document the total time spent.

Will payers know how much time I spent?

When you submit a CPT code for E/M office visit services, the payer doesn't know if you chose the chose by MDM or Time. It's if/when you get audited that you will need to show documentation that supports the code you chose.

Best practice is to document "which way" you chose your CPT for reference in the future because it's likely you won't remember how each visit was coded. Your note documentation should make it fairly obvious.

How will a payer know if I did the work on a different day?

In an audit, it is on the provider to prove your work was complete on the same day. The audit trail will know what day/time you were logged in, when you did the work you did, even if the timestamp is not in the Note. It is now standard for legal teams to request audit trails as well as medical records when doing malpractice or other forensic investigations.