For over 20 years the same guideline requirements have been used to determine the level of service for office and outpatient visits. Providers had concerns that these guidelines required some elements that were not necessary from a clinical perspective, not to mention the time it takes to document each visit. The Patients Over Paperwork Act joined together the Center for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) to create new guidelines that allowed providers to spend less time documenting and more time administering quality care to patients. The new guidelines streamline the documentation for history and examination to only what is pertinent to that visit, allowing the level of service to be determined by time or medical decision making. These new choices allow providers to use them on a patient by patient basis for more flexibility in the documentation. Although these choices have been previously used, the requirements have been updated to meet the expectations of these visits in today’s medical practice. Because these guidelines are in the CPT® 2021, unless otherwise noted by the insurance company, these documentation guidelines will apply to all insurance companies.
Because these documentation guidelines are effective from January 1, 2021, all providers and staff that are involved with office and outpatient visits should be aware of the changes. Also, electronic medical records system templates will need to be updated to accommodate the new elements for documentation. This webinar by E/M expert Lynn M. Anderanin will review all the necessary elements for the choices of time and medical decision making for attendees to walk away with the understanding of how to choose the level of service based on the new documentation requirements.