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How E/M Coding Changes Became an Urgent problem at AFC Memphis

The 2021 CPT® code, updated in September 2020 revised the coding guidelines for CPT outpatient evaluation and management (E/M) services. The last time the American Medical Association (AMA) made significant changes to this code set was nearly 30 years after they introduced evaluation and management codes.

The 2021 CPT Code Update

In 1992, the AMA developed the evaluation and management code set. It replaced prior service codes as they did not accurately reflect the level of effort professional service visits entailed. 

E/M codes were and still are categorized into groups such as office visits, inpatient, nursing facility and emergency room services. The three key components of these codes are: 

  • History
  • Physical Examination
  • Medical Decision Making (MDM)

The E/M guidelines generally lacked clarity. For instance, the codes didn’t consider time as a key component. In addition, the code descriptor language stated only typical time. To add to the coding woes, the AMA did not publish official guidelines on how to assign the correct level of E/M service apart from what the CPT manual indicated. To make matters more confusing, two sets of guidelines were published with different documentation standards, in 1995 and 1997.

The AMA revised these codes so they could take effect on January 1, 2021, and solve these issues. The most significant change is a new direction to base code selection and documentation on either MDM or Total Time. This is a concept the coding industry has supported for years.

Change is Inevitable in Healthcare

The E/M coding changes became an urgent problem for AFC Urgent Care Memphis. It was not only hit with revenue losses from COVID-19 but these E/M coding changes also impacted their revenue. 

Like most practices, the last year was tough for AFC Urgent Care Memphis, Tennessee. Patient volume dipped dramatically at the start of the COVID-19 pandemic for the small urgent care clinic (UCC). And along came the most significant medical coding and clinical documentation updates to date.

How the E/M Updates Affected AFC Memphis

The overhaul largely affected outpatient E/M services, a major driver of business for UCCs. In the midst of an economic crisis caused by the global pandemic, these changes led to more revenue losses.

“We were already taking a pretty severe hit due to COVID, with a decrease in patient volume by 75 percent initially. Then, we got hit with the new coding guidelines right about the same time.”

  • Alice McKee, MD, Medical Director – AFC Urgent Care

Source: RevCycleIntelligence

Fixing Suboptimal Coding at AFC Memphis

Dr.McKee explained that the urgent care clinic was doing more lower-level visits despite delivering the same high-quality care to its patients.

“There was a lot of revenue to be lost. It turns out that the most immediate thing we could do was improve the coding and billing functions, then the collections, since we couldn’t do a whole lot about the situation we were in.”

  • Alice McKee, MD, Medical Director – AFC Urgent Care

Source: RevCycleIntelligence

Evaluating People, Process and Technology

McKee evaluated people, processes, and technology to improve medical coding and clinical documentation at AFC Urgent Care Memphis.

The physicians at the urgent care clinic had been documenting visits using the old way of coding and documenting E/M services. Some physicians do not document certain services in order to save time or to prevent a costly audit. Under the new coding and documentation guidelines, these habits were simply leaving money on the table.

Changing habits took a lot of education about coding. A new process with a new technology helped to move that along, according to McKee.

Finding a Technology Partner – Exdion’s Role

AFC Urgent Care Memphis decided to avail the help of a technology solution to fill in a process missing from the clinic’s coding and billing functions to fix the urgent revenue problem. 

Exdion’s solution takes data from the EHR and practice management system and uses an artificial intelligence tool to parse through all of the clinic’s encounters—which numbered in the thousands—to identify potential revenue gaps. If the tool identifies a gap, it notifies the physicians through email to take a look at the documentation and provide the missing information to support appropriate coding.

Exdion’s technology solution helped educate physicians on not only new E/M documentation guidelines but also on the use of outdated codes that would lead to rejections, missing modifiers, and other coding errors. The solution also bridged the gap between what happens from the chart to the billing.

Source: RevCycleIntelligence

A stitch in time – AFC Memphis boosted its revenue by 25%

With the right people, process, and technology in place, AFC Urgent Care saw a 25 percent boost in revenue, which was a lifeline for the clinic.

“Small amounts of money add up to a large amount of money in medicine. If even one procedure is routinely not being billed properly, like a urine analysis or the administration of an injection, those things add up to large amounts of revenue being lost.”

  • Alice McKee, MD, Medical Director – AFC Urgent Care

Source: RevCycleIntelligence

UCCs looking to bring their processes up to code, assessing people, processes, and technology is key to preventing revenue losses during this difficult transition.

Exdion Health – your revenue integrity partner

We understand that as healthcare professionals, all you want to do is look at giving patients the best services you can. But the world depends on sustainable revenue to make things work. Without revenue integrity, most UCCs would have to go out of business. At Exdion, it is our business to enhance your revenue integrity using cutting-edge Artificial intelligence to enhance your E/M coding and revenue integrity. Get in touch with us and optimize your revenue integrity today.

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