The Transformation of Documenting and Coding for Neurologic Hospital Inpatient and Observation Services.

Landmark changes to documenting and coding for office or other outpatient evaluation and management (E/M) codes were implemented on January 1, 2021. To decrease clinicians' administrative burden, many documentation requirements were eliminated. In addition, major changes were made in how medical decision making and time spent on the date of the encounter are used to determine the level of service.

The Transformation of Documenting and Coding: Evaluation and Management Codes for Outpatient Neurology Services.

This article discusses the optimal ways to document and code for outpatient evaluation and management (E/M) codes. Since the changes for Current Procedural Terminology (CPT) codes 99202-99215 were finalized for 2021, they have been modified by the Centers for Medicare & Medicaid Services (CMS) in their Medicare Physician Fee Schedule and by technical corrections issued on March 9, 2021. The 21st Century Cures Act mandated that patients can access their notes and test results immediately.

Evaluation and Management Codes for Outpatient Neurology Services in 2021: Changes to 99202-99215.

Medical services can be conceptualized as falling into two categories: procedures and cognitive care. A procedure is defined as a surgical, medical, or diagnostic test performed on a patient, such as an x-ray, wound suture, surgery, or physical therapy treatment. Cognitive care, also known as Evaluation and Management (E/M) services, involves performing a medical history along with a physical examination and possibly ordering or reviewing diagnostic tests before formulating a medical opinion and initiating a care plan.

Coding in the World of COVID-19: Non-Face-to-Face Evaluation and Management Care.

Almost all medical care in the United States is delivered with the provider and patient in immediate proximity; this model is referred to as face-to-face care. Medical services can be apportioned as procedural care (eg, surgery, radiology, or laboratory testing and others) or cognitive care, also known as Evaluation and Management (E/M) services, in which the provider formulates an assessment and plan after obtaining information from the patient's history, examination, and diagnostic tests.Providing a medical opinion and plan using the telephone as the technology that links the provider and the patient is an example of a non-face-to-face E/M service.

Expanding incentives for coordinated, patient-centered care: Implications for neurologists.

Historically, payment for cognitive, nonprocedural care has required provision of face-to-face evaluation and management as part of general ambulatory or inpatient care. Although non-face-to-face patient care (e.g.