We recently published a post outlining the Revised Coding Guidelines for 2021 for Chiropractic E&M services.
In this post, we will review the new guidelines and offer further documentation guidance.
The E&M changes effective January 1, 2021 focus exclusively on TIME and MEDICAL DECISION MAKING (MDM) factors, which means you will select the appropriate level of E/M services based on the following:
1. The level of the medical decision making as defined for each service;
2. The total time for E/M services performed on the date of the encounter.
DOCUMENTATION REQUIREMENTS HAVE NOT CHANGED!
Keep in mind that, if you’re documenting properly, these changes will not affect the way you document the components of your E&M visit. What will change is the way you are using your documentation for E&M code selection.
Understand that it is up to you, the physician, to use Medical Decision Making OR Time to determine an appropriate level of service, or code, for an Evaluation and Management visit.
The decision to choose one or the other is completely up to you and can change patient to patient, day to day, or from exam to exam.
Don’t worry, this should be easier, not more complicated.
HISTORY and EXAMINATION
Even though History and Physical Examination are no longer be factors in determining E&M code selection, you are still required to obtain and document a “medically appropriate” History and Exam.
The nature and extent of the history and/or physical examination is determined by the treating physician. The care team may collect information and the patient or caregiver may supply information directly (e.g., by portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional.