Don Self & Assoc., Inc., Medical Business Consulting

NEW E&M PROGRESS NOTE - OV ONLY

ONLY FOR USE WITH 99202-99215

Since the rules for documenting the OV codes 99202-99215 have changed for 2021 (and I'm sure they will for the other E&M codes in 2022), we need to look at why they were changed and what Medicare and other carriers are looking for. The why is easy. Whether you like Trump or not, you're about to benefit from his Patients Over Paperwork initiative that he started in 2017. If you're a provider, you should be able to save up to 162 hours a year that you were spending in paperwork. If you're a patient, then you will benefit by not having to wait so long to get in to see your medical provider as they won't be spending as many hours on paperwork.

One problem is that some consultants will not change and they will not advise their medical providers to change. They will not help their clients if they make them continue documenting more and more info. The idea is that they do not have to document as MUCH now on Office Visit codes. The 2021 rules will be using either TIME or MEDICAL DECISION MAKING now to determine the level of code. There is no reason to make the medical provider spend as much time as they did last year (and every year since 1997) in marking off the ROS and PFSH and personally documenting the HPI (the MA can do that!) and examining 9 body areas or systems when those 9 are not relevant to today's problems. It's much easier now. I'm creating a new 15 minute webinar on documenting MDM (hopefully will have it on this page this week) and in the meantime, here is an E&M Progress Note for 2021 for Office Visits you can use, change, adapt, adopt or whatever you want to do with it. The idea is to document the MDM in the middle of the page, so that the provider lists the symptoms, diagnosis, problems in one area. After that, they document what data they reviewed or ordered. Below that, in the appropriate area, they document the risk (for instance, if there is low risk, state that in the Low risk area. If the provider is performing RX management, put down what meds are being reviewed or changed in that area. If the provider is making a decision to either hospitalize or not hospitalize the patient, put that in the high area. Yes - this means the providers will need to learn A LITTLE about this - but not a lot. Keep it simple. Document how many minutes were spent before the visit reviewing the chart ("3 minutes reviewing chart"), how many during the visit and how many after (on the same date!!!). This should simplify it - as President Trump intended when he created the initiative! If you want this in pdf format or Word format (so you can change it), you can see those below:

2021 will be a great year

2021 E&M CODE CHANGES FOR 99202-99215

CONGRESS made some last minute changes in late December which impacts the Medicare Physician Fee Schedule, delays implementation and use of G2211 until 2024, delays the restart of the sequester (2%) until the 2nd quarter of 2020 plus more. What they did not change was the E&M Documentation changes to the E&M codes 99202-99215 that take effect January 1st. This 45 minute webinar includes all of that and shows you how EASY is it is to document with the new rules.
Of course, most of our clients have been using these new rules (or very similar ones) on all of their telehealth since April of 2020 for Medicare patients.
Note that you can still watch the 1995-1997 Documentation guideline webinars that you will CONTINUE to use on hospital, nursing home, home visits, ALF visits, etc in 2021 on our E&M page at www.donself.com/em as these on this webinar are for the 99202-99215. Let us know what you think.

THREE FREE TEN-MINUTE WEBINARS TO HELP YOU

DOCUMENTING TIME

This 10 minute FREE mini webinar helps you understand when a physician or medical provider HAS to document time and how documenting that time can make a difference on the reimbursement. This one covers the Counseling &/or Coordination of Care, Prolonged Service Codes, Hospital Discharge and Critical Care coding

SELECTING THE E&M CODE - NOT FOR 2021

This FREE 10 minute webinar helps physicians identify which level of office visit, hospital visit, SNF visit or consult code to use, while staying compliant. This mini session also helps the provider see how easy it is to document the level 3, 4 or 5 visit and how you can bill a level 5 visit - even if the patient only has one or two serious diagnosis! Too often, coders have providers under-code, based on incorrect information. The rules for 2021 have changed FOR OFFICE VISIT CODES 99202-99215 ONLY. Consequently, Don hopes to have a new webinar for the OV codes within the next week added to this website.

SELECTING THE MEDICAL DECISION MAKING

A FREE (10 minute) mini webinar on How to count the Medical Decision Making components (FOR NON OFFICE VISITS) of the diagnosis, medical management, clinical and diagnostic lab, prescriptions, etc. Note that the new MDM rules are for the office visit codes only. You'll still use the information in THIS webinar for non office visit codes in 2021 (such as hospital, nursing home. ER, home visits, etc) The MDM can be used to select the level of Telehealth visit code instead of TIME and the MDM will almost always result in a much higher level of service than the time by itself, if the medical provider does a decent job of documentation.

FREE 13 MINUTE MDM 2021 - OV VIDEO