Dr. Nicole Aaronson on how ENTs should approach the latest coding and billing updates

Some ENTs will have to decide if they want to change their billing documentation systems after recent CMS coding updates, according to Nicole Aaronson, MD, pediatric otolaryngologist at Wilmington, Del.-based Alfred I. duPont Hospital. Dr. Aaronson spoke with Becker's ASC Review about these changes and other considerations around coding and payer rules.

Note: This conversation was edited for style and clarity.

Question: Can you elaborate more on the 2021 Evaluation and Management coding changes?

Dr. Nicole Aaronson: There's a CMS initiative called "Patients Over Paperwork." The premise was that they wanted to reduce the documentation and coding burden for physicians. They started with the office outpatient and management codes as their first step.

The only things changing now are outpatient codes 99201 to 99205 and 99212 to 99215. Coding was previously based either on having enough history and physical elements to qualify for a certain code or on face-to-face time with the patient. The big transition now is that they're going to be focusing more on medical decision-making rather than having all of those history and physical elements.

Q: How does that affect ENT practices and their billings?

NA: A lot of ENT templates are based on having enough history and physical elements to hit the appropriate code level. Now, a note doesn't necessarily have to document all those history and physical elements. A provider should still document everything needed for completeness of care for the patient, so that if a different provider saw that patient, that provider would have the complete picture.

That being said, there were definitely things that were documented that weren't relevant to the patient's care, but they were included because they were required for coding. Now, documenting those extraneous elements isn't necessary, because the code is based much more on medical decision-making.

In the old coding scheme, when coding was based on time, only face-to-face time was included. Now, if a provider bills on time, physicians can include things like the time they spent reviewing records, ordering tests, documenting, coordinating care. Basically, the code allows a provider to bill for all the time spent taking care of a patient even if it isn't that time spent in the exam room. So that's a big change in methodology.

Q: Could these changes have any effect on patient care?

NA: I think the only hazard would be if people change their templates in a way that really strips down their history and physicals, because they're not required for the coding and then that information disappears. 

I don't think most people would do that. When I was trained, I was taught that the purpose is that, if somebody else was going to pick up and take care of that patient, they would know everything that had happened and what the plan was so they could seamlessly pick up that patient's care.

Q: How often do major changes like this occur?

NA: There are always small changes. I think this is a different framework for how to think about coding and where the value in care is. I have not seen a big change like [this] in my career.

Q: What factors should ENT practices consider when deciding to update their documentation systems?

NA: I think practices need to think about each individual department's workflow, how notes are used, and how adaptable staff are to changes.

There are still places that use either traditional dictation models or artificial intelligence-assisted dictation models. I think in those practices using dictation, it won't be as big a deal. It's going to depend on every institution and how much familiarity they have with their EMR system and how much support they have for their individual EMR. 

For me, I'm an accredited Epic physician builder, so I understand how to build out new templates in Epic. So for me, it's easier to either build templates or have a conversation about what is needed with the IT folks and EMR folks in my hospital. Maybe in smaller practices where they don't have the same EMR resources and or in-house EMR expertise, that might be a bigger barrier to getting those things done. For a lot of organizations, once they've built a template, it doesn't change for a long time.

Q: What are your predictions for payer insurance rules in the ENT space?

NA: I think payers are going to keep paying close attention. I think the people who are billing a lot of higher-level codes are still going to be more likely to be audited. The goal of the payer understandably is to not pay for services that aren't provided.

I think there is a big shift toward thinking about things like value-based care. It comes in different models, from capitation to attempts to create treatment pathways. ENT has traditionally operated under a fee-for-service model, where more volume means more revenue. If the goal is keeping people healthy and avoiding specialist referrals, then that works against a fee-for-service specialist model. So that will have to be sorted out. 

I honestly don't have a projection for how that's all going to shake out. I think it's still going to be very slow over time. I think these ideas have been talked about for decades, and only incremental moves have been made so far.

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