Does the AMA and CMS collaboration go far enough?
LEXINGTON Physician burnout has reached epidemic levels in the United States. Typical
symptoms of physician burnout include loss of enthusiasm for taking care of patients and decreased satisfaction. There is also increased detachment, emotional exhaustion, and cynicism. Some of the signs of physician burnout include disproportionately higher rates of depression, substance abuse, and suicide. National statistics report that 400 physicians commit suicide annually. This threatens the health of both physicians and our patients!
The causes for physician burnout are complex and multifactorial, but the most significant contributor is the documentation burden for billing. The 2022 Medscape Physician Burnout & Depression Report (Kane, 2022) surveyed 13,000 physicians in 29 different specialties in 2021 and found that the burnout rate was about 42%, the depression rate was 21%, and 54% stated that the burnout had a “strong to severe impact on their lives.”
Over 60% of the participants reported “too many bureaucratic tasks, such as charting and paperwork.” Fortunately, there are new CMS office-visit coding guidelines which are simpler and more flexible. The hope is that physicians will have more time to spend with patients instead of doing clinically irrelevant administrative burdens. And hopefully, we can mitigate some of the stressors which contribute to our physician burnout epidemic.
It has been over 25 years since the coding guidelines for outpatient evaluation and management (E/M) services have been updated. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) collaborated to extensively revise the E&M coding guidelines for office and/or outpatient services. As of January 1, 2021, the new guidelines for E&M CPT office visits (99202-99215) became effective.
The major changes include: 1) eliminating the need to document required “elements” for history and physical exams (e.g., no more irrelevant Review of Systems documentation), 2) allowing the physician to determine whether to document using Medical Decision-Making (MDM) or total time, and 3) modifying the MDM to focus on tasks that affect the management of the patient’s condition rather than simply adding up tasks. The new guidelines model the SOAP format (Subjective, Objective, Assessment, and Plan), which many physicians are familiar with. Additionally, the new coding guidelines have clarified several gray terms from the past 1995 and 1997 E&M Coding guidelines. (Believe it or not, these have not been updated until now!) For example, the term “tests” includes imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel such as a basic metabolic panel is a single test. A unique test is defined by the CPT code set. For example, multiple results of blood glucose values are considered one unique test. Other concepts clarified include “independent historian,” “stable, chronic illness,” “acute, uncomplicated illness or injury,” and “combination of data elements.” For details of the new guidelines, visit: Code and Guideline Changes/ AMA (ama-assn.org) to download the PDF.
Let’s examine a sample case of a patient with known COPD who presented for a cough. For the history and physical, the physician should only document medically appropriate details for that patient at the time of the visit. In this particular case, the physician is expected to document any relevant history of the current illness to include PMH, SH, and ROS. However, the number of “elements” in each category is not mandated.
Next, the physician may choose to implement either the MDM or Total Time Spent. For the “Medical Decision Making” portion, there are three (3) elements: 1) number and complexity of the problem or problems the physician addresses during the E&M encounter, 2) amount and/or complexity of the data reviewed and analyzed, and 3) risk of complications, morbidity, and/or mortality of patient management decisions made during the E&M visit to include complications related to the patient’s problems, the diagnostic procedures, or the treatment. The physician is required to document the assessment of the condition and/or problems, how the diagnosis was achieved, and the thought process for selecting the management option. The documentation of each distinct test, document, order, or independent historians adds to a counter which will determine which E&M level was achieved.
Thus, to achieve an E&M level 3 (99203 or 99213), the physician needs to document and satisfy two of the three MDM elements. For Element: number and complexity of problem addressed, any one of these will satisfy the element: 1) two or more self-limited or minor problems, or 2) stable chronic illness, or 3) acute, uncomplicated illness or injury. For the Element: amount and complexity of data reviewed and analyzed, the documentation must satisfy at least one of the two categories: 1) category 1: tests and documents (meet any combination of two bullets: reviewed prior external note from a unique source, reviewed result of a unique test, or ordered a unique test, 2) category 2: assessment requiring an independent historian. Finally, for Element: low risk of morbidity from additional diagnostic testing or treatment, documentation of the shared decision making and commenting on the fact that the risk for morbidity is low. For E&M levels 4 and 5, the MDM requirements are more demanding; but the documentation is clinically relevant.
The other option is to utilize the Total Time Spent with patient. As expected, it’s the sum total of time the physician spent to provide the care to the patient. However, note that documentation of time for each activity is necessary to account for the care. Please refer to AMA’s guidelines for additional details.
Although I am excited about these new outpatient guidelines, I recognize that many colleagues will push back, arguing that the documentation requirement has simply shifted. While that is true, I would much rather document clinically relevant details about my patient than frivolous details to simply check a required box. I also recognize and stated in the introduction that physician burnout has many contributing factors. As an optimist, I just wanted to share that the major contributing factor to physician burnout has been addressed, perhaps not as strongly as many may want. However, I am willing to take any stride, large or small, toward reducing physician stress and burnout. One final note: it would be nice to have official education and training on how to implement this!
Tuyen T. Tran, MD, MBA, FACP, FASAM is CEO and co-founder of 2nd Chance Center for Addiction Treatment in Lexington. He is past-president and executive board chair of the Lexington Medical Society and KMA 10th District Trustee.