‘Tis the season! December brings the holidays, family traditions and the annual changes to the procedure code set and associated guidelines.

This time of year, Practice EHR completes a higher volume of requests for minor changes to the chart templates as providers prepare for a new year with new services or simple changes to the common drugs administered. 2021 will also ring in with new changes to the billing requirements for the Office and other Outpatient Evaluation and Management Services (99202 – 99215).

Documentation will continue to drive the assigned code. However, the current code requirements driving the documentation will no longer apply come 2021, so changes to your templates should reflect what applies in the new year.

January 1, 2021 the standard office visit services will no longer be supported by three of this component and four of those and a complete past, family, social history. The American Medical Association (AMA) has removed any requirements specific to the history or physical exam. These data elements are to be documented consistent with the presenting problem and needs of the patient encounter.

Document a comprehensive follow-up history, complete review of systems, extensive past family social history followed by a well-crafted physical exam including two additional bullets for the Gastrointestinal Tract/Genitourinary Tract (GI/GU) system and that 12 year old with sniffles will still not support a level five.

Document a three-word history of the present illness in a patient with multiple comorbidities, noncompliance to prior treatment plans, with multiple diagnostic reports reviewed that morning while you staged the chart, and you may have a level five.

It’s a brave new world in the land of coding office visits. Please make sure that each of your providers and billing staff have reviewed the presentation by the AMA (the good stuff starts on about page 13).

It is the time of year to review your templates and ensure that they still accurately reflect the care you provide. Coding guidelines are a key piece of the efficiency of an electronic health record (EHR) and yes, Practice EHR is ready to help you capture the face-to-face and non face-to-face time or the details behind your medical decision making in any template. Just reach out to your client services team.