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Getting Paid Today: Challenges and opportunities for independent practices


New legislation, as well as changes in patient expectations, present a host of challenges and opportunities for getting paid for service this year.

In a recent article in Physician’s Practice, we discussed the challenges surrounding getting paid for telehealth this year and beyond. This is an essential issue for independent practices, but it’s not the only one. New legislation, as well as changes in patient expectations, present a host of challenges and opportunities for getting paid for service this year.

E/M Office and Outpatient Guidelines Changes

For the first time in more than two decades, the AMA has revised the guidelines for office and outpatient visit evaluation and management (E/M) codes. It’s been a long time coming—effective this year, CMS has aligned E/M coding with the changes adopted by the AMA. For many providers, this means an increase in their revenue because they will finally be compensated for time spent in activities related to patient care that were previously not easily accounted for in the guidelines.

Clinicians are now able to choose codes for their new and established visits based on either time or medical decision making. Unlike the previous time-based options, which required that 50% or greater of the visit be spent on counseling and coordination of care, the new guidelines include total time spent by the provider related to the visit. This time includes non-face-to-face time spent on the day of the visit performing activities such as reviewing tests, obtaining or reviewing history, performing exams or evaluations, counseling and education of the patient/family/caregiver, and ordering medications, tests or procedures. It also includes communicating with other healthcare professionals and documenting clinical information in the health record, independently interpreting results, and communicating to the patient/family/caregiver, and care coordination.

With the new E/M guidelines, clinicians can now account for all the time they have been spending doing most of these things. One important note is that providers must document the time spent on these activities in their medical records to justify the coding in the event of an audit. This should be relatively easy to accomplish through updates to templates in most EHR systems.

The other option for determining the level of E/M code is medical decision making (MDM). This is not a new concept, as MDM has been one of three elements in determining the level of code for E/M services. The new guidelines, however, allow clinicians to choose MDM based on two of three elements: number and complexity of problems addressed, amount and/or complexity of data to be analyzed, and risk of complications and/or morbidity or mortality of patient management. The AMA has provided a Code and Guideline Changes document on the new requirements including an Elements of Medical Decision-Making table that illustrates the new coding guidelines.

Remote Patient Monitoring Can Improve Outcomes

Patients with chronic conditions who are following their care plan and managing their symptoms don’t always need an in-person visit. In addition to telehealth, adding remote patient monitoring for blood pressure and diabetes can help keep more chronic patients on track with their care plan. Studies have shown that patients who use remote monitoring devices are more consistent with taking their readings, and reporting to the provider is automated so it is easier to see changes in a patient’s condition that might require an in-person visit or an adjustment to medications.

New technologies and service offerings allow providers to engage a third-party vendor to provide remote monitoring equipment and train patients on how to use their systems to monitor and transmit their results. In many cases, the vendor provides monitoring of the patient to ensure compliance. By utilizing a third-party vendor for remote patient monitoring, an independent practice can free up staff time spent reviewing patient logs and can ensure better compliance for patients who may be prone to skip readings.

Surprise Billing

It’s worth mentioning that new surprise billing legislation has been passed that will prohibit providers from sending bills for out-of-pocket expenses that a patient could not have reasonably predicted. This primarily applies to services rendered in hospitals, particularly in emergency situations where not all providers are in the patient’s insurance network. Previously, the patient might receive a bill for the full amount of each (out-of-network) provider’s standard rate.

While the surprise billing guidelines likely will not directly impact many independent practices, they may have a positive effect in that patients will not find themselves crushed under unexpected, astronomical charges for healthcare. This new legislation will go into effect January 2022 and it would be worth it for a provider to review both the federal law and the laws specific to their state to determine how it might impact the practice.


The bottom line is that things are changing rapidly, and independent practices need to stay updated and aware if they are to avoid pitfalls and take advantage of new possibilities for getting paid today.

About the Authors
Terri Joy, MBA, CPC, CGSC, COC, CPC-I, is a billing subject matter expert at Kareo, with over 20 years’ experience in physician billing and revenue cycle management. Aimee Heckman, CPB, CPPM, is a healthcare business consultant with more than 30 years of experience in medical practice management, revenue cycle management, PM/EHR implementation, and business development. More information can be found at www.Kareo.com.
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