01/04/2021
Changes to Medicare that may affect you.
Medicare has been hard at work to address the documentation burden placed on clinicians, physicians, physician assistants, nurse practitioners, and other medical providers. Some major changes are beginning January 1, 2021 thru the “patients over paperwork “initiative. One initiative that has been launched involves streamlining how providers report and document their services. Medicare recognized an opportunity to help resolve provider complaints regarding the documentation burden associated with Office visits also known as Evaluation and Management (E/M) Visits. Clinical care involves complaint or symptom-based face-to-face encounters between a patient and clinician. The intensity of this work often requires complex medical decision-making and care coordination. Clinicians had to perform and document the visit with significant detail, some of which was (I think) of only marginal relevance to the visit. Beginning in 2021, billing and documentation for visits will be simplified.
The clinician will perform a “medically appropriate” visit and identify the “nature of the presenting problem” or reason for the visit as described by the patient.
The presenting problem is identified as
· minimal – Only needing a nurse working under the supervision of the clinician who may not need to be present in the room. i.e. suture removal for a simple repair of a superficial wound.
· Self-limited or minor which refers to a problem that is expected to have a definite course and is temporary or has a good prognosis. An insect bite is a possible example.
· Low severity - problems have a low risk of morbidity and little or no risk of death even with no treatment. A patient should be able to recover from this level or problem without functional impairment. An example might be sinusitis.
· Moderate severity problems have a moderate risk of morbidity or death without treatment. The prognosis is uncertain or extended functional impairment is likely. Some cardiac events may fit this category.
· High Severity problems have a high to extreme risk or morbidity without treatment. The risk of death with no treatment is moderate to high. Sepsis might fit this level.
If the patient presents with a moderate severity problem, the clinician may wish to bill the visit based on the level of Medical Decision Making. This includes establishing a diagnosis, assessing the status of a condition, and/or selecting a management option. Clinicians may bill their services base on the Medical Decision Making required to treat the presenting problem.
If the nature of the presenting problem is low but time was needed to counsel or educate the patient, the clinician may choose to bill the visit based on time. A visit typically includes preparing for the visit i.e. reviewing tests, getting or reviewing a history, performing an exam, counseling and providing education to the patient, family, ordering medicines, tests, procedures, documenting information in the medical record, and sharing that information with the patient plus care coordination. Time does NOT include activities the clinical staff normally performs.
A minimal presenting problem visit might necessitate only 15-29 minutes.
A low severity low risk (i.e. recheck of a resolving problem, or routine evaluation of a chronic problem) presenting problem may require 30-44 minutes.
A moderate severity presenting problem may require reviewing/ordering tests, a minor procedure, counseling, or providing education. The visit may require 45-59 minutes. The clinician will use “Total Time” to bill the visit which must be within the above times and the time must be documented in the record along with a description of the visit.
I believe a majority of visits going forward will be billed based on time. The patient's complaints of “the doctor was only with me for 5 minutes” may diminish because documentation of the visit is simplified and the time needed to complete it significantly reduced. Patients may want to identify the total time the physician was in the room with them. I encourage patients to access their medical record after every visit and read their physician's visit note. It helps us to remember instructions given, but also can identify any errors in the record or claims.
A personal example: My husband was scheduled for a heart catheterization and instructed to get a blood test the day before the procedure. When the Medicare explanation of benefits and physician bill arrived, that blood test was denied as “not covered”. I did a little research and discovered the wrong diagnosis code had been used to support the lab charge. The claim was refiled and the lab work was paid. That $300 charge was paid by Medicare at $8.00. A good reason to read every explanation of benefits and question all denied charges. You are the only one who will initiate getting corrections made.
If you changed your insurance this year, be sure you provide the new information to your physician's practice and validate that it was updated at several subsequent visits. One of the most common reasons for denied claims is invalid insurance or an error in the ID numbers.
