Resources from CMS and the AMA to Help You Implement Changes to Physician Documentation & Billing

Changes to Physician Documentation and Billing

There have been two major changes in the regulations pertaining to physician documentation during ambulatory visits, both of which are favorable for wound care practitioners. These changes have decreased documentation burden and redundancy. Implementing them can be a challenge in a hospital-based outpatient setting, where coders and other staff struggle to understand the difference in inpatient and outpatient (ambulatory) regulations:

Changes went into effect on January 1, 2019, which allow ancillary staff members to document certain parts of the clinical note that physicians can then review and verify, rather than requiring physicians to re-document. This allows considerable flexibility in the team approach to wound care documentation. Read the letter from CMS which discusses these changes.

An even bigger change went into effect on January 1, 2021 which changed the criteria for billing physician level of service (LOS), making these codes dependent on medical decision-making or time, and NOT the history or physical exam elements. This is a huge win for wound care practitioners whose physical examination is often highly focused, but whose medical decision making can be highly complex. The American Medical Association has an entire (free) tool kit to better understand this.

These changes reduced duplication in data collection, helped clarify billing rules, and removed specialty-specific challenges created by the previous guidelines that had been in use for a quarter of a century. Although it is frustrating to have to learn and implement new rules, for wound care practitioners, these changes are a big win because they enable practitioners to be compensated for the cognitive effort involves in wound/patient management, the complexity of the patients and their comorbid conditions, and the underlying medical risks associated with a chronic wound. These changes are part of Intellicure’s internal algorithm for physician billing, which, when used correctly, can facilitate correct billing under the new rules.

Caroline Fife, MD

Dr. Fife is Co-Founder and Chief Medical Officer of Intellicure, Executive Director of the US Wound Registry, and Editor of Today’s Wound Clinic.

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