Evaluation and management documentation guidelines
Effective January 1, 2021, documentation guidelines for office and other outpatient visits are based on two components:
- Medical decision making (MDM)
- Total time
Total time is the complete time spent on the date of the encounter and may now include the time spent before, during, and after the visit, as well as the time spent documenting the visit. Previous components of history and physical exams are no longer used to determine the level of service; however, a medically appropriate history and exam are required.
The 2021 guidance for time allows providers to receive credit with appropriate supporting documentation for the following elements:
- Preparing to see the patient (e.g., review of tests)
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests, or procedures
- Referring and communicating with other healthcare professionals (when not separately reported)
- Documenting clinical information in the electronic or other health record
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- Care coordination (not separately reported)
The intent of the revised documentation criteria is not to eliminate the need for providers to support medical appropriateness, but to provide them with the ability to account for additional time elements that were previously excluded.
CMS guidelines state the provider must help ensure that medical record documentation supports the level of service reported to a payer. Providers should not use the volume of documentation to determine which specific level of service to bill. The total time spent on the date of the encounter will determine the specific level of service billing. Services must meet specific medical necessity requirements in the statute, regulations, and American Medical Association and CMS manuals, and specific medical necessity criteria defined by national coverage determinations and local coverage determinations. For every service billed, providers should indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary.
Clear and concise documentation is imperative to providing quality care. It is the provider’s responsibility to help ensure the documentation furnished reflects services provided to receive accurate and timely reimbursement.
American Medical Association CPT® 2021 Professional Edition
CMA Evaluation and Management Services Guide Booklet, MLN06764
Documentation Guidelines for Evaluation and Management
April 2022 Anthem Provider News - Indiana