FEATURES

How E/M Coding Changes Became an Urgent Problem for a TN Clinic

AFC Urgent Care Memphis was not only hit with revenue losses from COVID-19 but also E/M coding changes. A new medical coding and billing strategy boosted revenue by 25%.

Source: Getty Images

- The past year has been tough for AFC Urgent Care Memphis, Tennessee. Like most practices, the small urgent care clinic saw patient volume dip dramatically at the start of the COVID-19 pandemic. And like their peers, this all happened during one of the most significant medical coding and clinical documentation updates to date.

On Sept. 1, 2020, the American Medical Association (AMA) released the 2021 Current Procedural Terminology (CPT) code set containing the “first major overhaul in more than 25 years.” That overhaul largely affected outpatient evaluation and management (E/M) services, a major driver of business for urgent care clinics.

Among the changes were eliminating history and physical exam as elements for code selection, allowing code level selection based on medical decision-making or total time, and providing more detail to CPT code descriptors and guidelines.

AMA explained that the new E/M coding and documentation guidelines would make the process “simpler and more flexible” for physicians and care teams bogged down by clinical documentation requirements. However, in the midst of a global pandemic turned economic crisis, the changes meant even more revenue losses.

“We were already taking a pretty severe hit due to COVID, with a decrease in patient volume by 75 percent initially,” Alice McKee, MD, a family medicine physician and medical director of AFC Urgent Care, recently told RevCycleIntelligence. “Then, we got hit with the new coding guidelines right about the same time.”

McKee explained that the urgent care clinic’s business was about to shift from a bell curve with a peak of Level 4 E/M visits, with some Level 3 and Level 5 visits, to one with a peak of Level 3, meaning the clinic would be doing more lower-level visits despite delivering the same high-quality care to its patients.

“There was a lot of revenue to be lost,” McKee stated. Those expected losses on top of the revenue drop as a direct result of the COVID-19 pandemic created an urgent problem for the clinic.

“It turns out that the most immediate thing we could do was improve the coding and billing functions, then the collections, since we couldn’t do a whole lot about the situation we were in,” McKee said.

People, processes, and technology

To improve medical coding and clinical documentation at AFC Urgent Care Memphis, McKee evaluated people, processes, and technology.

The physicians at the urgent care clinic had been documenting visits a certain way for so long (think, this was the largest overhaul to the CPT code set in several decades). They had created habits to ensure they documented visits according to the old way of coding and documenting E/M services. Furthermore, McKee understood that some physicians do not document some services to save time or prevent a costly audit.

However, those habits were leaving money on the table under new coding and documentation guidelines.

“Did you document your discussions that you had with the patient? Did you document decision-making? What about the pros and cons of choosing a certain treatment? Did you review any other materials or talk to people other than the patient,” McKee posited to the physicians.

“These are all thing that would improve the complexity of the visit, and if these things did happen, you definitely want to document them because that justifies your Level 4 or Level 5 visit, which has a better level of reimbursement. But it’s a totally different mindset.”

McKee said changing habits took a lot of education about coding, but a new process with a new technology helped to move that along.

With such an urgent revenue problem, AFC Urgent Care Memphis decided to engage the help of a technology solution to fill in a process missing from the clinic’s coding and billing functions. The solution from Exdion takes data from the EHR and practice management system and uses an artificial intelligence tool to parse through all of the clinic’s encounters—which numbered in the thousands—to identify potential revenue gaps. If the tool identifies a gap, it notifies the physicians through email to take a look at the documentation and provide missing information to support the appropriate coding.

The technology solution helped to educate physicians on not only new E/M documentation guidelines but also on the use of outdated codes that would lead to rejections, missing modifiers, and other coding errors. The solution also bridged the gap “between what happens from the chart to the billing,” McKee explained.

“There was no real process [before implementing the solution],” McKee stated. “The biller was expected to pick up on things, but nobody was checking.”

Entering the new era of E/M coding and documentation

With the right people, process, and technology in place, AFC Urgent Care saw a 25 percent boost in revenue, which was a lifeline for the clinic.

“I’m sure it saved the clinic because it wouldn’t have made sense to keep going the way it was,” McKee stated.

Fortunately, walk-in traffic is picking back up after the initial surge of COVID-19. The clinic also invested in the equipment to provide COVID-19 testing to patients, which proved to be an important service line for the struggling clinic over the last year.

But just as importantly, the clinic is now ready for a new era of E/M coding and documentation. AFC Urgent Care is continuing to educate its physicians on new coding and documentation guidelines to ensure more clean claims go out and the clinic receives the reimbursement that is truly owed for the services its physicians delivered.

“Small amounts of money add up to a large amount of money in medicine,” McKee stated. “If even one procedure is routinely not being billed properly, like a urine analysis or the administration of an injection, those things add up to large amounts of revenue being lost.”

For other clinics looking to bring their processes up to code, assessing people, processes, and technology is key to preventing revenue losses during this difficult transition.

“Don’t be too afraid of the technology and having people who check is extremely important, even if it is just routine audits,” McKee advised. “Every day there should be some system for checks and double checks.”