Understanding impacts from 2023 outpatient E/M coding guidelines

MGMA · Business Solutions: Understanding Impacts from 2023 Outpatient E/M Coding Guidelines

Listen and Subscribe

In this episode of the Insights podcast, we spoke with Juli Smith, director of strategic partnerships, ZOLL Data Systems about the impacts of staffing shortages and the No Surprises Act.

Editor’s note: The following Q&A has been edited for length and clarity.

Q: You recently spoke at an MGMA webinar on the updates and impacts from 2023 outpatient E/M coding guidelines. Can you give us an elevator pitch for that, Juli?

A: “The AMA (American Medical Association) documentation guidance is being significantly overhauled. The last time it was distributed in this manner was 1995, so we all have been married to the old guidelines for about 27 years. But January the 1st, a new groom is coming to town and there are significant changes. The great thing about that webinar is; it’s kind of like some great pre-marital advice. What’s coming? How do you tune in? How do you get prepared? Because your world is really going to change if you're utilizing the E/M codes, particularly in the area of medical decision making.”

Q: Give us some background then, you said the last update had been 27 years ago? Is this just like locusts, they show up every 27 years? Or what is the thought process?

A: “The truth is, it’s really complex. If you looked at the timeline, they tried numerous times to revise the documentation guidance for the E/M guidelines, and they just really couldn’t get to a central place. They couldn’t come to agreement – all of the stakeholders - (this update) was tried several times.

The fabulous thing is that CMS and the AMA, who produces CPT, are really for the first time in lockstep. There are going to be very few places where CMS policy differs from the AMA CPT guidelines, and that's really helpful to all of us. They're also really hearing the message that clinicians have been overburdened by documentation, overburdened by the clicks in the EHR. This revision is a very substantial step forward in (reducing) the documentation burden for clinicians. Let's do what we can to free them up for care.”

Q: One of the things you discussed in that webinar was how the implementation of the No Surprises Act is impacting reimbursements. Tell us about that.

A: “The entire process really was not ready to go on time. Clinicians, those ancillary to the hospital … are seeing delays in as much as six months in their payments. Worse, they're seeing a 20% to 50% decline in initial reimbursement. …

Not only is there a huge drop in reimbursement, the core data that's needed for the process to work is not there. What's profoundly unfortunate about that is, I'm aware of billing entities who have had to lay off huge amounts of staff because, without those payments, and with that much reimbursement decline, they’re simply not solid. I'm also aware of many, multiple, in the dozens, and of course - that's just what I'm aware of - clinician groups and provider entities, who have let clinicians go.”

Q: We’re seeing catastrophic levels of staffing shortages at times. What is that doing to reimbursements?

A: “For the last nine months, the AHA (American Hospital Association) has released a negative margin of on average .98 for hospitals, and that is a combination of the reduction in reimbursement, and also the incredible costs of traveling nurses, (because) they're paying a lot to get staff in. So it really is that double whammy; staffing all across the reimbursement process is more expensive. …

When we have fewer clinicians on the wall as America’s safety net in our emergency departments - fewer radiologists to read, and interpret, etc. - it's patient access. I'm a little bit biased here, but in a year, when the top five payers have seen more margin than Apple, more margin than Google, than Netflix, and our clinicians are negative margins, cutting pay, cutting hours. Ultimately, that impacts the patient, and we really have got to address that inequity in healthcare.”

Q: What are some, even initial steps that we can take to make that burden less burdensome? What are you thinking?

A: “We've really regulated the clinicians; we have not regulated health care insurance entities. And I'm not a fan of regulation, but I do think we have to do some things around how much of what the insurers are bringing in is being paid out to clinicians. What authority does an insurer have to deny care? That really is the practice of medicine. Texas recently passed legislation that said that only a clinician could deny care, because when we say a procedure is needed or not needed, are we not practicing medicine?

So I know I'll be in Washington next month lobbying for those very things. I encourage everyone here to get involved, send letters. We need the No Surprises Act to be implemented in the way that Congress intended, as opposed to how it has been rolled out. Those things will make a difference, but there's no quick fix, but t I certainly think there's a lot of money in the system. When margin beats out Apple, Google and Netflix, the money's there, let's get it to taking care of patients rather than profits for investors.”

WE WANT TO HEAR FROM YOU 

We'd love to hear from you. Tell us what you think. Let us know if there's a topic you want us to cover or an expert you would like us to interview. Email us at podcasts@mgma.com. 

The MGMA Insights podcasts are produced by Daniel Williams, Rob Ketcham and Decklan McGee. 

Sponsor:

This episode is brought to you by ZOLL Data Systems A.R. optimization solutions for healthcare. The ZOLL A.R. Boost solution suite increases revenue from payers and patients in compliance with the No Surprises Act while reducing front-end workload and freeing up staff for higher-value activities. Visit www.zolldata.com/arboost to learn how you can ensure no payments are left on the table.