The New E/M Requirements are About Letting Doctors Practice Medicine

February 26, 2021 Erin Palm

Good news for doctors who see patients in clinic -- taken together, changes in reimbursement and documentation requirements for ambulatory visits send a clear message that doctors should focus on patients, not billing rules.

New rules for documenting outpatient clinic visits came into effect on January 1. For CPT billing codes 99202-99215, the doctor is no longer required to document a certain number of History and Physical Exam elements to justify the level of care. Instead, the requirements emphasize the doctor’s Medical Decision Making.

At Suki, we’ve heard two kinds of reactions to the new documentation requirements. One reaction is, “Just when I figure out the rules, it all changes again. Billing requirements are so confusing.” The other is, “With the new rules, I can focus on communicating my clinical thought process. I no longer have to document findings that aren’t meaningful for the care I’m providing.”

We applaud the rule change because it helps reduce some of the administrative burden placed on doctors and allows them  to focus on communicating rather than clicking boxes.  Along with simplifying documentation requirements, CMS has also streamlined payment amounts, paying a single rate for levels 2-4.  Across the country, physicians are breathing a sigh of relief as they realize they can abandon forms and templates engineered for the old system. They are focusing on patient narratives and clinical assessments. Notes are becoming richer, less about checking boxes and more about communicating doctor’s reasoning for their plan of care.  Suki was designed specifically for supporting narrative style documentation: our natural language processing and machine learning algorithms let physicians quickly and easily document their clinical thinking.

So far, the new requirements only apply to clinic visits. We would encourage the American Medical Association and Center for Medicare Services to make similar changes for consultations and emergency visits, to help doctors focus on the practice of medicine in these settings as well.  Unfortunately, physician burnout affects doctors regardless of specialty; we wholeheartedly support regulation changes to lighten administrative workload and are here to help physicians tackle the rest.

About the Author

Erin Palm

Erin Palm, MD FACS is a general surgeon who practices with the Kaiser Permanente Medical Group, and serves as affiliated teaching faculty for the Stanford Department of Surgery. She completed her residency at Stanford Hospital and Clinics and fellowship in surgical critical care at LA County + USC Medical Center.

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