Modernizing Medicine’s Electronic Health Records (EHR) Systems Prepared for 2021 E/M Coding Changes

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EMA® and gGastro® EHR systems make E/M changes easier on physicians, allowing practices to bill based on time or medical decision-making (MDM)

BOCA RATON, Fla – January 26, 2021Leading healthcare technology vendor Modernizing Medicine® today announced that the company’s electronic health records (EHR) systems, EMA and gGastro EHR, are ready for the Evaluation and Management (E/M) coding changes that took effect January 1, 2021. With the aim of reducing physician burden and improving patient care, this landmark change represents the first E/M coding change in over 20 years and will impact coding and billing for all future office and outpatient visits. Modernizing Medicine has updated its suggested coding capabilities to reflect the new guidelines. For example, as of January 1, 2021, a clinician can choose to bill based on total time or medical decision-making (MDM). If they choose MDM, the platform will be able to automatically suggest the relevant E/M code based on the user’s clinical documentation and related MDM.

“Our medical and development teams have been hard at work readying our software for the E/M changes,” said Veronica A. Diaz, MD, Medical Director of Orthopedics at Modernizing Medicine. “Notably in the new guidelines, elements of the history of present illness (HPI) and physical examination will no longer be used in code selection for outpatient E/M services (99202-99215). Instead, complexity of the presenting problem and associated decision-making, as well as level of risk involved in management, will drive the determination of what E/M level should be billed. The updates we’ve made to our suggested coding capabilities will help our clients make this important transition with confidence as we continue to make strides in modernizing medicine.”

From its inception over 10 years ago, Modernizing Medicine has taken a specialty-specific approach to EHR design, which has resulted in an intelligent, intuitive platform that is preprogrammed out of the box with specialty-specific medical content.

Dr. Jeff Goodell, board-certified otolaryngologist and practice owner of ENT & Allergy, noted, “Since I already use EMA, I haven’t missed a beat. I did not need to spend any significant time changing my workflow or processes to be prepared for the coding changes. With a few simple clicks, I am able to document medical decision-making quickly and efficiently.”

About the 2021 E/M Coding Changes

The E/M coding guideline changes began with the Centers for Medicaid & Medicare Services’ (CMS) Patients Over Paperwork initiative, which seeks to streamline regulations and reduce medical documentation requirements to enable physicians to spend more time with patients while reducing burnout. The new E/M guidelines reflect changes made by The American Medical Association (AMA) and have been incorporated into the latest edition of the AMA’s medical coding manual, CPT 2021. Therefore, these E/M coding changes will affect not just Medicare, but national coding guidelines. Under the new rules, physicians will select an E/M code based on either the total time spent on the visit or updated MDM criteria.

  • Billing Based on Time: Physicians will be able to bill for time spent on a variety of different activities, including: documenting clinical information; ordering medications, procedures or tests; referring to or communicating with other healthcare professionals; counseling and educating the patient, the patient’s family or caregiver; as well as other tasks.
  • Billing Based on MDM: The 2021 E/M guidelines include changes to MDM criteria, moving away from adding up tasks to instead focus on tasks that affect the management of a patient’s condition.

The changes are summarized in this resource from the AMA. To learn more, join the Xtelligent Healthcare Media Reimbursement Virtual Summit on January 27 to hear Dr. Michael Rivers, director of EMA ophthalmology at Modernizing Medicine, speak on a panel around, “Coding and Clinical Documentation to Decrease Denials.”

You can also take Modernizing Medicine’s E/M readiness quiz here and read the company’s E/M Coding Guidelines blog or watch its webinars for more information.

About Modernizing Medicine

Modernizing Medicine and its affiliated companies empower healthcare providers and medical practices with a suite of solutions designed to transform how healthcare information is created, consumed and utilized to increase practice efficiency and improve patient outcomes. The award-winning healthcare technology company works with providers nationwide in the specialties of dermatology, ophthalmology, orthopedics, otolaryngology, plastic surgery, gastroenterology, pain management and urology, as well as ambulatory surgery centers. Modernizing Medicine and its affiliated companies provide a suite of solutions including the electronic health records (EHR) system, EMA®, and the GI-specific EHR, gGastro®. The healthcare suite includes Practice Management, Business Operations Services, Analytics, payment processing services and patient engagement tools such as telehealth. Built with the help of on-staff practicing physicians, the all-in-one EHR systems help provide a more complete picture into the clinical, operational and financial aspects of specialty medical practices with the goal of helping practices focus even more of their time on patient care. For more information, please visit Connect with Modernizing Medicine via its blog, Facebook, LinkedIn, Twitter and Instagram.


Matter for Modernizing Medicine

Alexandra Foley


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