Will the 2021 revised E & M codes restore some value to the intellectual side of patient management?
That question is open for now.
What does need to happen immediately is a change in your old coding habits.
When you stop the old cut and paste of physical exam findings and learn how to use Risk and Decision Making properly - a Level IV visit will most likely become your new normal and Level V much simpler to justify.
Learn Much More in our latest Physicians on Purpose Podcast:
POP Podcast 13:
2021 Evaluation and Management (E&M) Codes with Paul DeChant MD
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Do you think these new E&M Codes will make a difference in reimbursement in the long run?
TRANSCRIPT:
Dike Drummond MD:
Well, hello again, this is Dike Drummond, the next physicians on purpose podcasts. My, my guest today is Paul DeChant MD. He's a family practice doctor, a CEO, a LEAN Black Belt, and an expert in the new Evaluation and Management ( E & M ) coding changes that came down as we turned the year into 2021. And what I want to do with Paul today is to give you a 20,000 foot view on these, these coding changes the spirit in which they were written, how to actually think about coding in 2021, and how your thought process may need to change a little bit.
Let me start with a quick disclaimer, nothing we're about to share with you is meant to replace any sort of training that your employer or society or anybody else would want to put you through to tell you specifically what to code for what level of service.
So Paul, welcome to the show. Tell everybody just a little bit about who you are and what kind of doc you are and what your career course has been because you've had a very interesting career and then we can dive in a little bit into these E&M changes.
Paul DeChant MD:
Thanks. I'm happy to be here Dike. I really appreciate the opportunity. I'm a family doc. I practiced for 25 years. During that in multiple different settings during that time, had multiple different management roles as well. Practicing in the Bay Area in California. I spent eight years actually a great job. Practicing in Breckenridge, Colorado as a family doc and ER doc at the base of the ski hill, also did management there and merged five small groups into one. I worked at Geisinger, you know, one of the more premier known health systems in the country for a number of years. I was CEO of a 300 physician group in the Central Valley of California, and then spent the last six years actually consulting with health system leaders around the country on reducing burnout.
Dike Drummond MD:
Good golly, what have you not done.
Paul DeChant MD:
I would say I haven't gone to Disneyland, but I actually have. Not in the past year, that's for sure. Haven't gone anywhere in the past year. My work has been driven by practicing as a family Doc, running into barriers and frustrations that I would have trying to do my job connecting with my patient, figuring out what they needed and getting them the best care I could. There's so many multiple barriers and frustrations, all of us run into not sitting back and just dealing with it, but actually speaking up with the thought that I could make a difference. And then that would get me into a committee that got me to enter a leadership position, I gradually moved up leadership ranks in that process.
When I became CEO, it struck me I really had an opportunity to do something different. So I lead the organization through a transformation around the theme of returning joy to patient care about making a great life for doctors, so that they could then give great care to patients. Particularly, we needed that because we were in the Central Valley of California, which is not the most desirable place to live, especially when the Bay Area is only an hour and a half away. So we needed to have a great professional experience. So we could get great doc because the personal family experience was not as attractive as their nice towns Don't get me wrong, and I enjoyed living there. But in terms of trying to compete for recruiting against some of these other places, that was a challenge, right?
So in all of this, there are ways that we can fix the workplace. And my basic core philosophy now is the problem with burnout is the workplace, not the worker, and we can fix the workplace. And it takes a combination of many different things. We must have certainly support for individual physicians to deal with the challenges. Even if the workplace was perfect, we need that support. But there's so much we can do to fix a workflow. And there's so much we can do to fix the management system and culture to create support. that those are areas that I really focus on a lot, but lately,
Dike Drummond MD:
Hang on a second, I just want everybody to know with that introduction, Paul is going to be back for a future podcast to talk about the journey to leadership for a hard working smart family doc like him and what enabled him to make that transition to CEO. He's also going to be back to talk to us about Lean and process improvement. And today what we're going to do is just introduce you to Paul, based on his facility with E&M.
And if I can just interject, a lot of times when I hear people talk about we need to change the system. We need to change the laws. We need a union lots of different things that people call out for. You can change your own reality internally in a heartbeat. You can change your own practice fairly simply too, but you know what, there are larger forces in work and this particular set of E&M code changes that were rolled out here in 2021 are a piece of a movement to restore some balance to the force. So with that as a preamble, Paul is going to show us a little bit about how to change your thinking about billing and coding here in 2021.
Paul DeChant MD:
Okay, great. I love the way that you can capture it and put everything into perspective to help people understand what what we're talking about in ways that are meaningful to them.
Dike Drummond MD:
Oh, come on, you're making me blush.
Paul DeChant MD:
Disclaimers, that, that I whatever I say I'm not recommending that this is the way you code. And I'm not guaranteeing you, you know that this will work for you and your situation. These are concepts. And I'll talk some about some of the initial challenges that are happening because we're recording this right at the end of January in 2021. It's all just being deployed, and there's a lot of uncertainty that's cropped up since it's gotten started.
So the basic concept is that, you know, cognitive work has been under rewarded in healthcare ever since the ever since these four guidelines first went into place, and they first went into place, I was around back in 95, when they first got rolled out, and they were a mess, and people rebelled. And so they got fixed a little bit in 97. And the word was that within a few more years, they'd get fixed again.
Well, here we are 24 years later. And it's finally the next change. Yay, guidelines. You know, typically, the rate of which, you know, bureaucracy and government and everything work and what gets what happens. So, there's been tremendous amount of effort that went into designing this.
This is a huge change, because up to now, in order to get reimbursed, and to assign a code that felt like it was worth the value of the effort you put into your visit with that patient, you had to gather a lot and capture a lot of information out of the history, including past social family history, you know, and multiple reviews, some reviews of multiple systems. And then in your exam, again, you had to capture a lot of different issues in the exam, and then understand some fairly arcane issues around medical decision making and how to get credit for what you did in medical decision making.
Dike Drummond MD:
Unless you just pulled out a scalpel and cut them in charge for the church.
Paul DeChant MD:
And then the other unless is if you just bill on time, but in inevitably, you can do far better with your productivity and your compensation. If you're billing the charges based on the RV use rather, or whatever it is the medical decision making following the system, and billing just on time.
The new process completely gets rid of anything, anything that needs to be recorded in the history and physical. It's all on medical decision making. So that's a big change.
And a lot of people historically have been copying and pasting previous notes into the current note in hopes that it'll capture past social family history and things like that, that you no longer need to do. And in fact, one of the problems with the old system was it created so much note bloat, because people would think if I just put a whole bunch of stuff into a note, somehow what I need to have in there, so that when a, when an auditor comes in checks my note, they'll find it and I can justify my, the code that I assigned. That's not you don't need to worry about that anymore.
Dike Drummond MD:
Hang on a second. Let's just delineate this as clearly as possible without with everybody realizing this is not this is our interpretation in January 2021 of what this means, no longer does it appear that you have to do what?
Paul DeChant MD:
You don't have to capture the elements of the history and physical in order to assign your code your level 2, 3, 4, 5. It's gotten away from that now. You want to document pertinent stuff from your history and physical, obviously. And that can make a difference just in terms of then justifying what you include in your medical decision making.
But in terms of what's going to get audited, that what gets audited are three components of medical decision making
- One is the problems, the number and complexity the problems
- Second is the data. And there's a variety of data in ways that data gets captured and identified.
- Third is Is the risk. And risk is very specific, it's the risk of the treatment or approach that you take with the patient.
It's not the what we traditionally think of as this patient's at risk, because they've got multiple, you know, multiple illnesses, or their or their diabetes has progressed so far. That risk is all incorporated in the problem element, the first element, not in what when the risk element is all about the risk of what I'm doing to the patient on STEM. And that's one thing that people get confused on.
Dike Drummond MD:
So if I, if I'm going to associate a little metaphor, or a word phrase, I'm gonna say in previous years, the the code was front loaded, there was stuff that you put into the HMP on the front end that determined the code. Now we're backloaded. Right? Yeah. And you're saying that risk is not how risky the patient is? Because of their characteristics? Risk is what I'm doing with the patient.
Paul DeChant MD:
Previously, much of the documentation you needed to get your code was front loaded, we call it the top of the note. In the old SOAP approach, you know, in fact, there's been a lot of talk in the last few years about changing soap note to APSO, because let's face it, if you're going to look at somebody else's note, you're not going to waste your time looking at the history and physical, you go right through what's the assessment and plan that that person had on that last note? That's what I need to know to know what I'm doing next. And maybe I'll fill in the details if I go to the history and physical.
Dike Drummond MD:
Well, I've got a question for you, because I've been a patient recently. And I've talked to a lot of doctors who have been patients recently, and those of us that are old school, right boomers, I'm 62. We’re appalled by the quality of the physical exam, we don't get these days. And so what about documenting physical exam in the new in the new era here in 2021?
Paul DeChant MD:
It's not there's no required documentation of the physical for this for using this coding system.
So say if a patient's got so let's back up a little bit. You know, if you're seeing a patient with congestive failure, and you know that the key question in the problem element of this is, how severe is that is that a particular chronic disease the patient has? Well, if you can document three plus bilateral lower leg edema for congestive heart failure patient, that's an important piece of the physical exam, you want to document in your exam. You want to have pertinent physical exam, but you don't need anything else. And I agree, things have changed, you know, I mean, nobody would ever let me use a stethoscope through a shirt on somebody when I was going through my training. But now that's commonplace.
Dike Drummond MD:
What I don't have to do is I don't have to lie about having looked in their ears and looked in their throat, and all this stuff that gets copied and pasted in, that didn't happen.
Paul DeChant MD:
Right, you don't have to use that template that automatically pumps everything in. Hopefully, we won't see so many men having pelvic exams, and so many women having prostate exam. Because we're just not going to be using those automatic template things. And there's no need to do that anymore. You could just simply put in the pertinent positives. And then if there are any negatives, but you certainly don't have to go through the whole thing. Excellent. And it won't make a difference. In fact, so one key example, if you work in an urgent care, and you get a new patient that comes in and that patient's got unstable angina, and you're packing them up to get them to the end as fast as possible. In the old system, it was really hard to get to a 205, which is what you would really deserve the 995 for that patient, new patient with really high acuity. Because you have the documents so much. history and physical that didn't really matter in order to get the number of elements that you needed,
Dike Drummond MD:
Right! Here they are with unstable engine. And did you do a rectal exam? Give me a break?
Paul DeChant MD:
Exactly, you know? Yeah, did you check 12 reviews of symptoms? The problem is an acute unstable problem that's, you know, threatening life and your decision making his decision to send that patient to hospital. That's all you need to charge a level five. And so it's that's much better. So we can briefly go through what each of these elements entails. And maybe that would be helpful.
The problem element now, and so it's, they call these three divisions of it the elements of that problem element The data element and risk element in the problem element, there's acute problems and chronic problems.
And in your acute problems, you know, you're looking at what's your differential diagnosis of this patient to get to that problem? How severe is that problem? Are there other? Is it a potential that this is going to worsen into something else like a UTI turning into pyelonephritis? Is this problem going to be causing? You know, is this problem due to some other problem, all those factors come into the level of risk involved with that condition? Not the risk of the carrier providing the risk of the condition. And that's what we normally think of as risk. But so that's we have to kind of think differently.
And, and so it ends in so with, with acute problems, you go through that, that quick assessment, for chronic problems, what you're assessing is, what's the progression? What's the, what's the status of this chronic problem? Is it just is it you know, is it totally well controlled? Is it mildly progressed? Or does it have severe progression, and there's parameters around which to look at that, you know, the, my, the well controlled, stable, chronic problem, that's not worsening, like a patient with blood pressure, I've got hypertension, you've seen them once a year, they're on their meds, they're stable, they're doing fine. Well, there's not very many patients like that anymore. Anyway. And that's, that's your level three patient is that person who is perfectly stable comes in for a once a year check and has no other problems.
But you know, you're lucky, if they're 5% of your practice, at least in terms of giving a break in your day. Usually, it's less than that. And almost everybody with a chronic disease already has either that chronic disease is not well controlled, or has progressed some or that patient has, has more than one chronic disease, in which case, that's already a level four visit from the problem standpoint.
Dike Drummond MD:
So if I got if I've got coronary artery disease, or hypertension, I've got diabetes, Level IV, right?
Paul DeChant MD:
That's going to be at least level four visit for sure. Because you'll be gathering data that you need to to assess all those, and you're going to be making most likely making decisions. So there's some new things that have you know, in recognizing cognitive work, even though it's something we don't think of is such a big deal.
You know, managing a hypertensive patient on a combo mid with an ace combo with a with a diuretic, and you're checking their, you know, you're refilling their med, you may be checking a renal panel. And right there, you're at a level four visit.
And, and that that alone, you know, you think, oh, wow, that's a level four. But when you realize, it doesn't seem like a big deal to you, when you're doing that, but you have done this, you do it dozens of times a day, 1000s of times a year 10s of 1000s of times in your career, where you automatically go through just rapidly go through all the assessment and evaluation it takes to make those decisions. You're just so good at it. But it's because you've had all the training skill and experience to get there that gives you that and that training, skill and experiences of value. And CMS is now starting to recognize that. So never feel guilty. If you're meeting the what the what the directors of the coding guidelines say, never feel guilty, about, about assigning that code.
Dike Drummond MD:
Well, and what I'm going to do is just bring in the thought about an elite athlete, right? When you are practicing your craft as an elite athlete, the highest level is unconsciously competent, right? So they even say Michael Jordan was so on fire tonight, he was unconscious, it's like, well, you do it automatically. But that doesn't mean that it's any less complex than the first time you did it.
Paul DeChant MD:
Right. Except the first time you did back in medical school, it took you two hours and you got it wrong. Right? And now you can do it and 15 seconds and you get it right. And it's because of all that experience that makes such a difference.
So yeah, so the problem there's it breaks into acute or chronic with the chronic. There's these you know, there's a there's a stable, chronic disease that shows no sign of worsening, that's a level three, a level four is progression. If you need to know if a patient who actually is on multiple meds can be considered a patient with progression. If the patient's not at their target. That's considered progression. These are level four conditions. And if and then if a patient has severe, severe progression, so that they're actually severe progression.
One specific example of this is a diabetic on insulin. Now you wouldn't think a nurse should know if you've got a diabetic they've gotten insulin for a while there will control the great a one sees their stable as a rock. You know, would that patient be a level five patient from a chronic disease standpoint? What the What CMS is looking at this as is that underlying disease state or pathology has progressed to the point that that patient can't control their glucose without exogenous insulin. So that's a, that's a significant disease that you're taking care of. And even if you're able to take care of it and keep it very stable, there's significance there in the degree of work intensity and knowledge you need to take care of for that patient. So that's a level five. You mentioned earlier, you have an endocrinologist that you've talked with who says all their visits are level five now that they're right there. And you know, anybody who's on insulin is that problem element is level five,
Dike Drummond MD:
Well, and my friend who said that is also and I, I sort of held my breath when she said it, she says, I'm the fourth largest prescriber of insulin in the United States of America.
Paul DeChant MD:
That's a busy practice.
Dike Drummond MD:
if I if I can just stop for a second. High risk. Yes, I can kill you with insulin in about 15 minutes. Yeah. So the fact that they're on insulin is not only the severity of the disease, but the risk involved in the treatment?
Paul DeChant MD:
Well, so that's an interesting point, because that that's one of the things that's still being debated and worked out in terms of the actual understanding the definitions of the risk element. Because in the risk element, there's if you think of Level Three, four, and five, oh, you notice we're not talking about level twos at all, because a level two is is a minimal problem with minimal data and no risk at all.
Dike Drummond MD:
Well, that's somebody who doesn't need to see a doctor.
Paul DeChant MD:
Exactly, exactly. It's kind of like, you know, if maybe if your pediatrician you're doing an ear, recheck, and the kids perfectly well, that counts. If a patient of yours notices a skin tag on themselves, they don't know what it is, and they decide to come in and see you punish, that.
Dike Drummond MD:
That's a skin tag.
Paul DeChant MD:
That's it. So really, the issue is what it is, to get to level five, from a risk standpoint, in terms of, I'm sorry, level four risk from a medication standpoint would be over the counter medications. From a from a level four, from a risk standpoint, it's a prescription. And it doesn't matter whether you're refilling a med, or starting a med, it doesn't matter whether that means amoxicillin, or, or a combo, antihypertensive or insulin. All meds are considered a level four, if you're managing the medicine, if you're refilling it, if you're starting it. That's, that's, that's level four.
For level five regarding medicines, you have to screen for a toxic effect of the medicine. So if you start a diuretic, and you check a renal panel that's considered screening for toxicity, because it's a negative effect, not the intended effect of the medicine, right? with insulin, at least right now, it's not clear, you're giving insulin for the therapeutic effect, not for a toxic effect. And if you're checking it, and then the reason to, to the reason to get that level five credit isn't the medicine you've prescribed. It's screening for the toxic effect. And if you're checking a glucose after adjusting insulin or any, you know, hyperlink, oral hypoglycemic, you're essentially checking for two things, you're checking for the therapeutic effect. And you're also checking for potential toxic effect, but depending on who you talk to about the interpretation of that they may interpret it, that if you're screening, if you're checking glucoses, or a one sees after you've made a change in diabetics, treatment, that's really looking not at the toxic effect, but it's a therapeutic effect in the sense, that doesn't count for level five risk for that. That's the kind of arcane stuff that happens. level four.
Dike Drummond MD:
Let's just put another disclaimer in here. Like you said earlier, we're in January 2021. Obviously, if you know what you're doing, you're going to be coding higher than you did in 2020. The real question is, how will the marketplace equilibrate? So for instance, are the are the folks at the payers and remember, there are hundreds of payers in the United States of America? We don't just have one like in Canada, where we could get a single answer. But are they going to start rejecting your claims willy nilly gonna throw a billion of them back in your face? Or are they going to accept these over time, get get beat down to accept these but then cut your payment? You were telling me about payment again, earlier, Paul. So let's talk a little bit about about payment too. And I don't think that you tell me I don't think we're probably going to know how this recalibrates in the marketplace until probably what third quarter of this year when it all shakes out.
Paul DeChant MD:
No idea how soon that'll be with you know, so many things up in the air right now. What is known is that the RVU values for each of the E&M codes, has gone up somewhere between 10 to 25%, depending on the E&M codes, so there is you know, there's actually an increase in the up. Not only can you code it a higher level, because the rules are designed to give you the opportunity, using E&M codes to code them at a higher level. But each E&M code actually has a higher RVU value associated with it, what the payers will likely do is they're not going to impact the RVU value, they'll change the conversion rate of the RV on what that RVU value turns into dollars. That's where the issue would come up.
The other issue could come up in how tightly they audit the notes. And I don't know if there's going to be a clear national standard for some of the intricacies around the other requirements like in the data elements, you can get credit for ordering a test or for reviewing a test or if you do if you do an EKG in the office, but a cardiologist is going to override that. But you use you do your own reading to make a decision about caring for that patient in real time. That it's possible in some approaches, you can actually get some additional credit for that in your data element. But there's questions about that as well, that vary from group to group from peer to peer.
So there's an awful lot of messiness that still needs to get worked out around all of that as well. Cool. So you got to just do your just, you know, take the guidance you can get from the best sources you can get within your own organization or from, you know, other organizations. You know, I know the AAFP has been putting out a lot of stuff about how to code properly, you know, and others are as well, the AMA, you know, they design these, they've got a lot of guidance out there. And you can look at all of that, you got to try to make the best honest decision, you can and then go with that from there.
Dike Drummond MD:
And philosophically, this is meant to be a pendulum swinging back, rewarding cognitive work at a higher level to restore some of the imbalance that has been in favor of procedural work for a while.
Paul DeChant MD:
And procedural Doc's are not happy about this, because it's actually in order to in order to add more compensation for for cognitive work, CMS has actually ratcheted back on compensation for procedural work.
Dike Drummond MD:
And so now what do you know how far they ratcheted back? This? I
Paul DeChant MD:
I don't have I don't know the relative numbers. And, and I imagine it may even vary, you know, especially by specialty procedure by procedure.
Dike Drummond MD:
Interesting, interesting. Interesting, lovely. So, is that enough of an aliquot of E&M code stuff for now, Paul? Or do we need to give and put a couple more things in? Or is that a pause point for us?
Paul DeChant MD:
You know, I think just to briefly review, what are the key points out of what I said, the focus, you don't have to blow to the front of your note. There's no value in adding anything other than what's actually pertinent to the care of that particular patient.
Secondly, pay look closely at the rules and the guidelines, and the definitions that go with those guidelines.
- In terms of what the problem is, what, what's your, in your problem element? Is it acute or chronic? And what level is it at?
- In the data element, we haven't talked too much about it. But there's an awful lot of opportunity in the data element there.
- And then, in the risk element, the risk is not about the patient's risk, the risk is about the risk of your treatment of the patient can think of it in that way.
And one last quick note, the way that these codes get assigned is there's those three elements, they each get graded to a level, you know, two through five. And then the rule is that you take the lowest of those levels, and eliminate that and assign the code for that visit to the next highest level. So if in your visit, your problem was a level three, your data was a level four and your risk was a level five, you would eliminate the level three, and this would be a level four visit.
And then because there's no difference between New and established patients. Now, if it's a level four visit, that's a 204. If it's a level four is if it's a new patient, it's a 204. If it's an established patient, it's a 214. You don't have different rules for new and established patients.
Dike Drummond MD:
Gotcha. Anything else they need to know? For now,
Paul DeChant MD:
Hang in there for. Don't be surprised if things change, and don't get frustrated with the coders you work with. If they're coming and telling you that things are changing. It's not their fault, the whole the whole country, the whole system's going through figuring this out. So I figure it's going to change some just you know, and roll with it.
Dike Drummond MD:
Right. And I think the whole thing is going to be fluid. You know, what are the payers do when these codes start to change and they violate their algorithms and they're seeing you as a liar, they're gonna have to reset their systems for monitoring folks with the frequency of the of the level fives that they produce, there's going to be changes in conversion rates and all of that. And then let me go to the, to the final, the last mile as they say, there's probably going to be adjustments in your compensation formula from your employer. At some point, too, because what we've been talking about is what the payers pay your employer, there could be internal adjustments to comp formulas as well,
Paul DeChant MD:
Absolutely. No, every every, you know, health system, Medical Group, whatever they're going to have to figure out is all of a sudden everybody's productivity starts to change. How does that change the redistribution of the compensation money within the group?
Dike Drummond MD:
Yep, yep. Because that's where your paycheck comes from. It's a translation of funding from the payers through the overhead of your group. And whatever is left, a little bit as ever left is coming into your paycheck. Right on. Well, Paul, thanks so much, really appreciate it, Paul DeChant MD. He is he's one of the good guys of LEAN, a family doc and Ex CEO. He's gonna be back here to talk about his leadership journey and about, you know, 16 different ways that you can really screw up when you use LEAN as a weapon instead of a process improvement technology. We'll have him back on a bunch of future shows.
Paul DeChant MD:
I'm looking forward to it. Thanks.