Providers Must Modernize MDM and RCM Processes To Preserve Revenue Under New CPT® E/M Code and Guidelines

Along with a new year, January 1 will usher in watershed changes to the American Medical Association’s (AMA) “Current Procedure Terminology (CPT®) Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Coding and Guidelines.” Medical providers and coders have relied on these standards for more than two decades.

Understanding the 2023 changes is key to identifying and abating areas of potential revenue loss in the coming years. 

Appropriate medical record documentation ensures responsive treatment, optimized follow-up care, and builds a care road map for fellow providers. Robust documentation within electronic health records (EHR) can also ease claims processing and help capture the greatest allowable reimbursement. However, with landmark changes on the horizon, many once-optimal best practices no longer apply, according to Juli Smith, healthcare revenue optimization expert and director at ZOLL Data Systems. Understanding which ones do apply is becoming a matter of urgency as 2022 winds down.

“In order to maintain financially healthy medical practices that can provide the exemplary care we all value, we have really got to understand the new requirements evaluation and management guidelines and how to engage with those requirements in a way that reduces administrative burden, optimizes revenue, and allows continued quality patient care,” Smith said.

Preparing for Change

While the CPT guideline overhaul addresses aspects of care such as facility charges, injections, infusions, and more, the most significant changes center around the provider’s documentation of medical decision making (MDM). The AMA has articulated a desire to better recognize a provider’s time, thinking, and treatments while reducing the administrative burden required to do so. The AMA-designed revisions are also intended for the most part to align with 2023 Centers for Medicare and Medicaid Services (CMS) payment policy revisions. This focus on documenting MDM results in a far more nuanced environment for the coder than under 1995 guidelines.

There are three defining elements of MDM:¹

1. The number and complexity of problem(s) that are addressed during the encounter
2. The amount and/or complexity of data to be reviewed and analyzed, such as:
   1. Each unique test, document, order, and/or discussion with an independent historian
   2. Independent interpretation of tests
   3. Discussion of health management or test interpretation with an external physician, qualified healthcare professional, or other appropriate source 
3. The risk of complications and/or morbidity or mortality of patient management

Smith recommends supporting medical providers who chart patient visits, as well as those who code these interactions. She advises creating a strategic plan to educate teams on patient documentation best practices to ensure adoption, and then to audit and monitor compliance. 

“Develop and deploy documentation and coding reviews specifically for this transition,” Smith said. “You’ll want to increase the cadence of those reviews and improve the feedback provided to be sure that providers and coders are getting the new coding and guidelines under their belts in the first and second quarters of 2023.”

Providers can explore external data sources to bolster MDM. For example, they can consider social determinants of health and look at essential health data. A platform such as ZOLL® Care Exchange enables access to near-instant aggregated patient data on procedures, medications, and outcomes from across the healthcare ecosystem, including emergency medical services (EMS) patient care reports and prior external notes.

Assess Potential for Loss

Medical practices that want to calculate potential reimbursement loss under the new guidelines can take current records, perform a coding audit, determine what current reimbursement levels are, and note any increase or decrease compared to reimbursement under the old guidelines. By applying this information to average patient collections data, a practice can forecast whether to expect increased or decreased revenue under the 2023 guidelines. 

Smith cautioned that small, avoidable errors in demographic data, such as a transposed Social Security number or the wrong birth date, can aggravate the revenue loss. In fact, nearly half of insurance denials originate on the front end of billing.²

“Unresolved denials can result in a total reimbursement loss or create self-pay situations,” she said. “Commercial healthcare payer compensation could be much higher than the average self-pay amount. Using an automated insurance discovery tool with patient demographic verification ensures real-time, quality patient information. It really does add up.”

Enhance Efficiency and Optimize Reimbursement

To ensure best practices, reduce overall cost and burden, and optimize reimbursement, Smith also recommends these steps:

• Leverage an automated insurance discovery tool with patient demographic verification to quickly and cost-effectively obtain accurate data up front.
• Eliminate manual processes and automate eligibility and prior authorization processes to reduce administrative burden and increase revenue. 
• Monitor claim status and consider an automated claim status tool to investigate multiple claims simultaneously.
• Explore self-pay analytics and propensity-to-pay tools that offer near real-time insights into what patients can afford, and where discounts or payment plans might be appropriate. This information paves the way for price transparency and compliant, patient-centric pricing.
• Improve patient satisfaction and your financial bottom line by making it as easy as possible for patients to meet their financial responsibility. 
• Monitor patient deductible status to help time claim submission. 
• Apply compliant prompt-pay and charitable discounting when appropriate.
• Request payment at the time of service 

As 2023 CPT E/M changes loom and medical providers project potential revenue losses ahead, the value of a best-in-class, cloud-based software solution such as ZOLL® AR Boost® to improve clinical, operational, and financial outcomes, has never been greater. 

“It's more and more important to make sure you’re not leaving anything on the table because of an antiquated revenue cycle process,” Smith said. “There are tools out there, they make a significant difference, and your staff will be happier for having them.”

This article is a collaborative effort with ZOLL Data Systems.

¹ American Medical Association, “CPT® Evaluation and Management (E/M) revisions FAQs.” https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management-em-revisions-faqs

² Change Healthcare, “The Change Healthcare 2022 Revenue Cycle Denials Index.” https://www.changehealthcare.com/insights/denials-index