E&M Documentation Seems to Remain the Same

Why are providers not using the new rules to their advantage?

This past week, I was sitting in a new client’s office (finally!) in Georgia reviewing ear, nose, and throat (ENT) documentation. I temporarily lost my audit focus, because I started thinking back to how, at the beginning of the new year, many of us were holding our breath as to what impact the American Medical Association (AMA) evaluation and management (E&M) changes would have on the “end product” of documentation.

As I stared at the notes in front of me, I realized that they, like thousands of records we have reviewed so far this year, actually lacked any changes to them at all – which, ironically, left me quite perplexed.

I thought back to when we were updating our E&M Bootcamp training literature and were revising the sample encounters for the hands-on exercises at the end of each chapter. I was hesitant, thinking hmm, what will we see? Will providers continue to document the template-style note they do today, or will they short-step it and give a very concise history and physical (H&P), followed by the assessment and plan?

Today, here I sit, well on the other side of 2021, completely and utterly perplexed as to the lack of change we have seen to the average E&M encounter – like, zero change. I think we have a big question to ask here: are providers missing one of the greatest opportunities that has been afforded them in the office setting in 25 years? And the natural follow-up to that is: why are providers not using the new rules to their advantage?

I think it is easier to start with the last question and work our way toward seeing if we can find an opportunity. First, some history: most providers were monetarily coerced into electronic medical record (EMR) systems with promised rewards of greater reimbursement through advanced coding that was supported through template-efficient documentation. At first, our providers resisted; they didn’t like the EMRs as they entered our offices, but as technology has begun to occupy most parts of our lives (personal lives included), they have become the mainstream of accepted clinical documentation.

We could think of EMR use beginning at first as an electronic filing system, but over time it has evolved into a documentation AND storage solution system, using electronic documentation through “smart” electronic tools. Such tools include copying and pasting, templates, macros, etc. If you have ever heard me speak before, you know I usually say the problem with these “smart” tools is that they are usually not used in a smart capacity – and, therefore, they often work counterintuitively for the provider. My point is that these tools are truly where I personally believe lies the answer to the “why.”

Why are providers not using the new rules to their advantage? Convenience. It is much easier to open a pre-built template, auto-import, and update or revise than to start over again with a new note or build new templates.

Using the existing templates created pre-2021 does not contradict any rules. Documenting a complete history of present illness (HPI), review of systems (ROS), past medical and social history (PFSH), and exam will not in and of themselves lead to deficient audit findings; however, our providers are missing out on the opportunity afforded them to document the way in which the majority of providers have voiced as their preference, which was aligned with the SOAP (subjective, objective, assessment, and plan) note format.

The SOAP note encourages a “subjective” interview with the patient to truly identify and elaborate on the severity of the issue, according to how the patient perceives their own problem to be. This allows better clinical interaction, free of checklist demands that were required by 1995/1997 documentation requirements. The “objective” evaluation of the encounter is one in which a clinician would use their expertise to include relevant observations about the patient. Over the past 25 years, the template approach to exams created more of a to-do list that at times appeared meaningless within the medical record. While the A&P (assessment and plan) has remained pretty much intact over the years, what EMRs have unfortunately delivered is a copy/pasted A&P that can rarely show differences from one patient encounter to the next, tempering the complexity of the encounter for the reader.

While the Centers for Medicare & Medicaid Services (CMS) began down the path of change that AMA has delivered for 2021 for the purpose of administrative burden relief, we knew there would be some initial investments of time necessary to create models of efficiency in a new era of documentation. But most have chosen to avoid it. The totality is the patient story, right? And hasn’t that been the problem since the inception of templates, and one of the other reasons many rallied for changes to the guidelines?

Templates and stern requirements regarding how a patient encounter is documented tend to change – and at times, strangle – the story of the patient. This burden has been removed, but has yet to be embraced. The next question we must ask ourselves, as we move into the second half of year one of the new guidelines, will be: how do we create interest in making this transition to improve the quality of recordkeeping for each and every consumer in healthcare – including me and you?

Programming Note: Listen to Shannon DeConda today on Talk Ten Tuesdays at 10 a.m. Eastern.