Top Challenges 2021: #2 Getting paid and seeing enough patients

Generating enough revenue to keep a practice open requires knowing the intricacies of medical coding to make sure reimbursement is maximized while also recognizing trends that keep patients coming back.

Getting paid is regularly listed as a top challenge facing physicians, according to the 2020 Medical Economics® Physician Report.

The good news for physicians who primarily deliver office/outpatient services is that CMS has made significant changes to Evaluation and management (E/M) coding and documentation to make the process simpler.

For 2021, there are three areas physicians need to focus on to make sure they get paid.

Understand E/M changes

E/M codes are now much simpler, according to coding experts. Physicians will not select an E/M code based on total time spent during the encounter or medical decision making, whichever one pays more.

For medical decision making (MDM), gone is the complicated points system derived from the number of treatment options, complexity of data and morbidity risks. The new MDM table includes easy-to-understand requirements and compensates them for complex cases, regardless of time spent, as long as documentation supports medically necessary services.

In addition, physicians now get credit for many tasks, including reviewing and interpreting test results, speaking with family members if a patient cannot provide their own history, and discussing patient management with another health provider or other professional involved in their care.

For time-based billing, physicians can now count the total time on the date of the encounter that may or may not include counseling and care coordination. Doctors may also count, among other tasks, documenting clinical information in the EHR, ordering medications or tests, preparing to see the patient, and referring the patient to and communicating with other health care professionals.

Physicians should contact their payers to verify whether they will adopt Medicare’s changes. Some payers may continue to require code selection based on history, exam and MDM. They may also have requirements for individual codes.

The most important thing is to ensure everything done matches the documentation.

“Remember that if it’s not documented, it didn’t happen,” says Dreama Sloan-Kelly, M.D., CCS, president of Dr. Sloan-Kelly Consulting, a medical coding consulting company.

Master telehealth payments

The COVID-19 pandemic closed many primary care offices throughout the country, forcing physicians to quickly adopt telehealth as the only way to see patients and keep revenue coming into the practice.

To say telehealth was a lifeline for practices is an understatement. According to Medical Economics® 2020 Technology Survey, more than 93% of physicians used telehealth to see patients during 2020, and 77% of them were using telehealth for the first time.

The Centers for Medicare & Medicaid Services (CMS) and private payers made a number of emergency exceptions to laws to make telehealth more accessible for both patients and physicians, and reimbursement for virtual visits was added or increased to match payment rates for in-office visits.

But the Medicare changes were made as part of the federal government’s public health emergency declaration, which will end whenever the pandemic has passed. While no one knows for sure when the pandemic will pass, doctors need to be ready for a sudden shift in telehealth reimbursement. In addition, some private payers have already rescinded reimbursement for certain telehealth visits as public confidence for in-office visits has increased.

Experts say physicians must balance keeping telehealth available for patients who are not comfortable coming into the office to capture as much revenue as possible with the fact that at some point in 2021, it’s likely that reimbursement for it may dry up.

Before the pandemic, telehealth reimbursement was extremely limited. Even if reimbursement remains for some services, it may not be at the same level as for an in-office visit, so doctors need to understand the return on their telehealth investment both now and when the public health emergency ends.

Embrace the data

Experts say fee for service isn’t going to vanish in 2021, but more contracts will be focused on value-based care, and the lifeblood of any value-based care contract is data. Payers want data to evaluate which physicians are the most effective, and the top performers get the best bonuses.

Participating in the most lucrative forms of value-based care requires that physicians have plenty of data on their outcomes and can show improvement and the ability to keep patients out of the hospital. An investment in software and equipment may be necessary to fully master all the data points within a practice, but without it, doctors will be at a disadvantage to both participate in and excel at value-based care.

“The key is for us to really break the fallacy that fee for service is a good way to pay for primary care,” says Farzad Mostashari, M.D., the former director of the Office of the National Coordinator for Health IT and currently CEO of Aledade, a company that assists small practices with transitioning to value-based care models. “We shouldn’t be basing primary care payments on that — it should be on the value created and we need to move towards more person-based rather than
transactional.”