The challenge of successfully running a physician private practice has never been greater, given the strains of the continuing COVID-19 pandemic, inflation, staffing shortages and more.

The free AMA Private Practice Simple Solutions rapid-learning cycles help physicians seeking to flourish in private practice by offering pre-recorded webinars and message boards that offer opportunities for participants to interact and to submit questions to the experts who present during the webinars.

“We want to learn from each other … and I’m really excited to learn with you and from you,” said Jeannine Z. Engel, MD, an AMA member and a University of Virginia associate professor of medicine, who presented during “E/M Documentation and Coding: Update for Ambulatory Visits.” The first webinar in this learning series covers outpatient evaluation-and-management (E/M) guidelines and related Current Procedural Terminology (CPT®) codes.

You took care of the nation. It’s time for the nation to take care of you. It’s time to rebuild. And the AMA is ready. The AMA Recovery Plan for America’s Physicians is rebuilding critical components of our profession by:

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Reducing E/M documentation burdens

Reducing E/M documentation burdens

In addition to the webinar and discussion board, there is an AMA STEPS Forward® Simplified Outpatient Documentation and Coding toolkit, which helps private practices:

  • Understand guidelines.
  • Engage key players.
  • Design workflows.
  • Educate physicians and staff.
  • Use the new E/M codes.

The E/M coding-and-documentation reforms began in 2019 with the Centers for Medicare & Medicaid Services (CMS) issuing a rule allowing physicians and other qualified health professionals who bill E/M services to use the documentation on a patient’s history of present illness and past family social history that was entered by nurses, nursing assistants, scribes, students or the patients themselves.

“The goal of these changes was to reduce redundancy and the documentation burden for the physicians and qualified healthcare professionals,” Dr. Engel explained, adding that many EHRs have built-in workflow functions for this purpose, but they may need to be activated.

More changes came in 2021, including the flexibility to select a level of service based on the complexity of medical decision-making or total time on the day of service.

The changes were designed to reduce the administrative burden for documentation and coding, lower the need for audits, and cut unnecessary documentation in the medical record that was not needed for patient care, said Dr. Engel, an internist who serves as the American College of Physicians’ adviser to the AMA CPT Editorial Panel.

Dr. Engel provided a sample of CPT E/M codes with the number of relative value units assigned to them by CMS and the fee that physicians receive for those services in her home state of Virginia. She also linked to a CMS resource (PDF) that physicians can use to determine the fee they will receive for that service in their state.

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Deciding on decision-making

Deciding on decision-making

Dr. Engel described how the level of medical decision-making—either straightforward, low, moderate or high—was based on using two of these three elements:

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