(For the sake of brevity, this will be Part One (of two or three) about professional billing.)

I start many of my talks with one fact:

Notes in the US are bloated with what many THINK are required for billing.

This misconception coupled with EMR’s abilities to auto populate and auto template has resulted in many providers filling their notes with as many words as possible HOPING it’s enough to satisfy billing.

Educate providers on what PRECISE language is needed for billing, and we’re 50% of the way with reducing note bloat.

Worse yet, providers have told me that consultants who audited their charts told them they were “over billing.” When I looked at their charts, I determined that they were under documenting - a subtle, yet importance difference. They did the work; they just didn’t document it. But they don’t need MORE documentation, but more PRECISE documentation.

In med school and residency, we’re taught “billing.” But what is “billing?” What this really means is “professional billing.” More specifically it’s E/M (Evaluation and Management) services. That is the charges providers drop for the services THEY provide.

For context there is also hospital billing which, obviously, is what the hospital gets paid for…essentially everything else. This is the focus when I write on preventing denials and clinically validating your diagnoses.

But to understand the new guidelines you have to understand the old guidelines.

The old 1995 / 1997 guidelines

To determine level of service, the old guidelines were based on the extent of:

• Number of qualifiers of a chief complaint

• Review of systems

• Past medical history, past family history, past social history

• Number of organ systems + bullet points under those organ systems for the physical exam

• Medical Decision Making or Time

  • Time had to be face-to-face and >50% spent counseling / coordinating.

The new 2021 / 2023 guidelines

• “Medically appropriate” history

• “Medically appropriate” physical exam

• Medical Decision Making or Time

  • Now includes total time and is not only face-to-face.

That’s it.

Yes, review of systems is GONE. And the extent of the HPI and physical exam is UP TO YOU (so you can stop pre-populating them, please).

The new requirements are substantially simplified. But remember: Minimal billing requirements are not minimal documentation requirements. And minimal billing requirements are certainly NOT minimal doctoring requirements.

Below is the new MDM chart:

Additionally, observation charges were deleted and merged with inpatient charges. Example:

A complete breakdown of the new guidelines and the MDM chart is outside of the scope of this newsletter, but I will clarify some of the frequently asked questions I get about the updates and MDM chart.

Frequently Asked Questions

• Do I have to meet all 3 requirements in each row? No!

  • You only need TWO out of THREE columns (or elements) to meet that level.

  • Example: Your documentation shows that you’re managing HTN and Diabetes type II and you increase metformin to 500mg BID. You met enough for a moderate level with “2 or more stable, chronic illnesses” and “prescription drug management.” You didn’t need the middle data column at all.

  • Example: Your documentation shows you’re treating a severe COPD exacerbation, and you personally made the decision to admit the patient to the hospital. You have enough for a high level with “1 or more chronic illness with severe exacerbation” and “Decision regarding hospitalization.” Again, we ignored the middle data column.

• For “prescription drug management” do I need to show that I’m managing every medication I mention?

  • No. You only need one to satisfy that requirement.

  • I tell providers that saying, for example, “On statin” does not satisfy that requirement. You must specify that you’re managing it somehow - either increasing, decreasing, stopping, starting or continuing. If continuing, I include a statement such as “as LDL is at goal.”

  • You should also include the exact medication, dosing and frequency. So, “Continue atorvastatin 40mg qhs as LDL is at goal” would be ideal. That often gets an eye roll, but you ONLY need to include that degree of specificity if you’re using it as an MDM point. If not, say it however you want (although I like the specificity from a communication standpoint).

• Does a prescription need to be created for “prescription drug management.”

  • No, but it does require your “prescriptive authority.” So, over the counter medications don’t count.

• Does “external” mean an outside hospital?! - No.

  • External means “not in the same group practice or is of a different specialty or subspecialty.”

  • Example: As a hospitalist, I cannot get an MDM point for reviewing the nocturnist note as we belong to the same group. However, I can get credit for reviewing the infectious disease consultant’s note.

  • Nurse practitioners and physician assistants working with physicians are considered to be in the exact same specialty and subspecialty as the physician.

  • Do you have to summarize the note? The AMA doesn’t specify that like it did with the old “review and summarization of outside records.” However, best practice is to document something you gathered from the note for the sake of specificity.

• Can I get credit for texting with a physician for “Discussion of management or test interpretation with external physician?” I like to include the direct AMA quote here:

  • “The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous (ie, does not need to be in person), but it must be initiated and completed within a short time period (eg, within a day or two).”

  • Does that imply “text-based communications” are allowed? Yes.

• Can I include a generic statement in all of my notes that I reviewed the PCP’s notes to get credit for that? (I get this question, or something similar to it, often)

  • My top legal advice for notes is this: do not document something you didn’t actually do. So, did you really do that? Did you do it every day for every patient for every note you wrote? If not, then don’t document it. Generic statements and auto populations like that have resulted in the note bloat we all struggle with today. Billing is simply not something you should have on auto pilot for the most part. Legally, you don’t want to hold yourself accountable for something mentioned in every PCP note ever.

  • I recommend being specific. “I reviewed Dr. ID’s note from this morning re: switching to Daptomycin.”

  • Remember, for defense against audits and down-grades, specificity is king.

• Do these statements have to be in the A&P? No!

  • In fact, because specific language is required which can muddy the A&P (and take away from its conciseness, readability, and reduce efficiency), I recommend keeping these statements OUT of the A&P - particularly in a section of the note which is NOT copy/forwarded so your billing statement is specific to THAT day.

  • But, sometimes you CAN check off billing requirements in the “natural language” of you A&P. I’ll talk more about that in my next newsletter.

That’s all for now. I hope that was helpful!

Feel free to reach out and ask questions as they help inspire future issues. Comments are turned on!

Cheers,

Robert

When you’re ready, there are two ways I can help you:

Check out The Resident Guide to Clinical Documentation. The course that helps you:

• Prepare you for “real-world” productivity pressures by optimizing your notes for efficiency.

• Prevent medical errors and lawsuits by using notes to stay organized.

• Gain the confidence to write shorter yet more effective notes.

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