Critical Thinking Leads the Charge Changes to E/M

It is an interesting time to be in healthcare. From the quality-based focus with the patient at the nucleus, our eyes are on a positive patient experience with optimal outcomes.

The changes to evaluation and management (E/M) for office and other outpatient services (O/O) that were developed by the American Medical Association (AMA), supported by the Centers for Medicare & Medicaid Services (CMS), and that commenced January 1, 2021 are one more example of the emphasis on the patient and quality. Prior to January 1, 2021, the directives for all services were the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services (DG), and these remain in place today for all services except the office/other outpatient settings.

The 2021 O/O changes fundamentally diverted the focus of E/M code assignment, per CMS, from the details of the history and examination components (which and how many body systems are involved) to two pathways of either medical decision-making or time (2018, p. 130), both of which have the foundation of critical thinking.

Critical thinking in medical decision-making (MDM) has always been at the core of the patient encounter; however, due to intrinsic and extrinsic factors, the focus on code assignment according to documentation of the details overshadowed the focus on code assignment according to documentation of medical decision-making. The provider has historically approached the patient encounter in the same manner, with each decision based on the information they had at the time. The provider’s critical thinking and MDM begins with the awareness of the reason for the encounter. Whether the patient presents with a new problem, a follow-up, or an annual visit, for example, the provider begins to formulate a plan on that small amount of information. The information gathering and critical thinking during the MDM process continues with each new piece of information. For example, if the patient’s only problem is foot pain, the provider is unlikely to begin an encounter with a history and examination focused on the patient’s respiratory system.

This is not to say history and examination are not important components, they are, but only in the sense that they relate to the patient’s health status at that encounter. The 2021 E/M O/O guidelines are clear in stating only a medically appropriate history and examination is expected to be documented (Holden, 2020).

It is essential to remember the impact of critical thinking and medical decision-making on the pathway of time. MDM is intertwined with the time pathway – so much so that the time pathway might be chosen because more complex MDM is required than is usually necessary in a typical encounter. With complex encounters come complex documentation; therefore, detailed documentation of the events and critical thinking/MDM that necessitated using the pathway of time is expected. This being stated, it is understood that the time pathway should not be considered a “get out of documentation” pass.

In order for there to be consistency and for providers, patients, and payers to operate from the same place, definitions and/or explanations are necessary. This has been recognized by the introduction of a significant number of definitions in the 2021 O/O E/M guidelines that had traditionally caused confusion over the past several decades with the 1995/1997 DGs. The management of a problem, risk, and stability are examples of such definitions.

The definitions begin by clarifying a problem as a “disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter” (American Medical Association [AMA], 2021 and Holden, 2020).

The clarification of what constitutes a problem being managed or addressed is welcomed, for those terms are widely used and often misinterpreted. AMA (2021) and Holden (2020) define a problem as being addressed when there is documentation that is evaluated or treated at the encounter by the provider reporting the service. Additional information in the definition highlights documentation of the consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice is a problem that was addressed/managed.

Another recognized element is the awareness of the risk of complications and/or morbidity or mortality that drives every decision and ultimately, the encounter. A provider considers the risk in each decision – the risk of the problem to the patient as well as the risk of the management options to the patient. Documentation of the consequences of the problem(s) addressed when they are appropriately treated is the foundation for the level of risk.

An example of how risk is ingrained in every decision is in the definition of “stability” which states that an individual who is not at their specific treatment goal(s) is not considered to be stable, even if the condition has not changed and there is no short-term threat to life or function. The risk of morbidity without treatment significantly factors into the determination of stability of an individual’s problem. An example of documentation of stability might include, “stable and at goal” or “stable but not at goal” (with supporting documentation of the details of continued management).

In today’s healthcare system, these decisions are not made alone; the patient is an integral part of the conversation regarding the problem(s) and any recommended/planned tests, medications, procedures and other options.

There is no doubt that the 2021 O/O E/M guidelines set the direction toward an positive patient experience with optimal outcomes and we can look forward to expansion of similar guidelines into other E/M services in the future that support the patient at the nucleus of healthcare.

References

American Medical Association. (2021, March 9). CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes. Technical corrections.

Centers for Medicare & Medicaid Services. (2018). Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program. Proposed rule. Department of Health and Human Services. https://www.govinfo.gov/content/pkg/FR-2017-07-21/pdf/2017-14639.pdf

Holden, K. (Ed.). (2020). Current Procedural Coding Expert. 2021. Optum360.