By EHRA Clinician Experience Workgroup

In January of this year, CMS adopted new billing guidelines from the American Medical Association (AMA) regarding E&M coding. The new guidelines include a wide variety of much-needed changes focused on streamlining billing processes and reducing clinical documentation burdens.

Seeing this as a watershed moment for clinical documentation and an opportunity to produce shorter, more clinically focused notes, the American College of Physicians (ACP) partnered with the Electronic Health Record (EHR) Association. Together, we examined the practical impacts of the coding changes with our community of vendors and clinical stakeholders, specifically:

1. What consensus about documentation burden exists across vendors, healthcare organizations, and specialist societies when interpreting the guidelines?
2. What questions, if any, exist around the guidelines?
3. How can we effectively educate the community about the impact of the guidelines?

Vendors, specialist societies and healthcare organizations were invited to provide input on the AMA guidelines, with particular focus on areas that directly impact documentation burden. Following the close of comments in late March of 2021, we produced a summary report that includes clarification from AMA, as well as comments from American Academy of Physicians (AAFP), ACP, American Academy of Pediatrics (AAP), American College of Cardiology (ACC), Cerner, Endocrine Society, Epic, NextGen, Office Practicum, and Sparrow Health System.

A common sentiment identified in discussions is that clinical notes are often weighed down by misinterpretation of older and outdated regulations. In response, we convened a virtual working summit with a mission to produce actionable deliverables with the potential for immediate impact. Forty-one attendees met to examine the latest AMA guidelines and create sharable examples of “good” notes to promote improved documentation choices for primary care and medical specialty care.

Attendees were presented with “bad” notes that were bloated, overly focused on billing, and did not leverage the EHR well. Breakout groups then created a “good” version that integrated the latest E&M changes as well as general best practices for clinical documentation. As the ACP’s Dr. Peter Basch said in his opening remarks, it was “necessary work, but hard, and we need to focus on making shorter, more relevant notes.”

The EHR Association’s Clinician Experience Workgroup assimilated output from the summit into three documents:

1. An infographic of good clinical notes for Primary Care
2. An infographic of good clinical notes for Medical Specialties, using Orthopedics as an example
3. A summary of recommendations for EHR vendors

Our hope is that these will be distributed widely for display in clinicians’ offices–especially those who are being weighed down by rumors that including the entire problem list in their note or writing out the entire physical exam are the only ways to get paid.

The ACP and the EHR Association think of this as the beginning of an ongoing conversation. For its part, the AMA is committed to continuing to refine their guidance, and is listening to the community as we all begin to implement the E&M changes. It is important that work begins with the coding and compliance communities to ensure that stakeholders are up to speed and comfortable with reducing clinical documentation burden.

We are extremely grateful to our attendees, our partners, and the community for their participation in this important first step.