The following is a guest article by Amit Jayakar, Vice President Commercial Operations at Fathom.
Earlier this year, the American Medical Association (AMA) released its CPT Evaluation and Management (E/M) Code and Guideline Changes for 2023.
These changes directly affect medical coding teams and providers’ day-to-day job responsibilities and how they capture services to receive quick and accurate reimbursements. From the perspective of revenue cycle management (RCM), the updates may create revenue uncertainty.
While any changes to the status quo can cause anxiety, especially when they tie directly into revenue, with the proper knowledge, preparation, and technology, medical organizations can stay on track to reach their 2023 RCM goals.
What’s Changing?
Beginning January 1, 2023, emergency department E/M guidelines are shifting to focusing on Medical Decision Making (MDM).
MDM is a provider ranking system that determines the complexity of establishing a patient’s diagnosis and treatment. These rankings range from very straightforward to high complexity. Per the current guidelines, whichever level the provider decides on is one factor that informs which E/M code gets assigned to a specific encounter. The other two factors are patient history and a physical exam.
According to the 2023 CPT updates, patient history and physical exam components will no longer factor into the final code. Instead, code selection is based solely on MDM. The AMA notes that while a patient history and physical exam should still occur, they will not be a determining factor in the assigned level of E/M service. This update intends to create a more simplified, flexible process for documenting E/M services.
However, that’s not to say this update won’t create any new operational challenges or concerns among team members. This is a significant shift in guidelines that will require preparation, education, and training to keep staff informed and prevent costly errors.
Potential Impact on Revenue Cycle Management
There is uncertainty in how an organization’s E/M acuity levels, and subsequently, revenues, will change under the new guidelines.
Before explaining further, it is important to understand relative value units (RVU) and how they tie into revenue. RVUs don’t represent an exact dollar amount but instead reflect the value of a service based on the time, skill level, and effort a physician gives during an encounter. RVUs help set up a standard format for comparing all medical services. An organization’s volume of RVUs is a deciding factor in reimbursements.
There are different types of RVUs; however, we’re referring to work RVUs, which combine the time and acuity level of a service based on its given CPT code. A larger volume of high-level work RVUs results in more reimbursements.
The 2023 guidelines updates may affect medical organizations that account for receiving a certain amount in reimbursements based on work RVUs. Per the proposed calendar year CY 2023 rule, only code 99281 is experiencing a decrease in work RVUs. Codes 99282-85 work RVUs will remain the same.
In light of these changes, many providers and revenue cycle organizations are unsure if their current operations are sufficiently aware, trained, and prepared to prevent any decrease in reimbursement from improper coding.
What Your Organization Can Do To Prepare
Education, training, and automation are excellent ways medical organizations can prepare for the 2023 guideline updates.
Thorough provider education is crucial. All providers must receive training on adequately documenting MDM thought processes to ensure coding personnel can assign their encounters with the correct code. On the coding team’s end, providing educational opportunities that outline exactly how the updates affect their day-to-day activities is vital to minimizing any errors that will translate into lost revenue.
Combining a well-educated staff with automation technology is a massive game-changer in getting ahead of these updates, as well as any future changes.
The shift in focus to MDM will be most challenging for physicians who need to tidy up their documentation practices and those managing large pools of manual coding. Implementing automation technology can make this update process easier and more seamless for everyone involved.
Setting Your Organization up for Success in 2023: Test Automation Technology at Scale With AI
Leverage AI-automated technology to recode a large volume of data with the new framework. We recommend using at least one month’s worth of data to ensure you receive a comprehensive view of how your coding may be affected.
Evaluate the coded encounters under the 2023 guidelines to understand and estimate potential shifts in your organization’s RVUs. Then, you can identify and prioritize any providers who need to adjust their documentation practices.
Perform these tests to give your team better visibility into what lies ahead and, ultimately, be more financially successful in the new year.
About Amit Jayakar
Amit Jayakar is Vice President, Commercial Operations, for Fathom, a deep learning NLP system that accelerates medical reimbursement, and is backed by world class investors including Google Ventures, 8VC, and Stanford. Mr. Jayakar, who can be reached via Linkedin, earned his bachelor’s degree in economics from Georgetown University and his masters of business administration from The Wharton School.
