Although the signs were there, with the distractions of COVID-19 many providers did not realize that there was about to be another transformation of huge proportions on top of all the activities already being faced with the pandemic – historic changes to the Evaluation and Management (E/M) coding.
Some of the changes have significant impact on Urgent Care centers in particular and will require specific retraining of providers to ensure all of their medical decision making is properly documented so it is fully accounted for in the visit. Some changes do make it easier for Urgent Care providers to focus on that day’s visit vs. documenting unrelated H&P elements. Finally, some changes are clearly problematic for Urgent Care, and UCA is addressing those with the AMA.
Disclaimer: Please understand and accept that this article and the Coding Grid Resource is merely our best collective interpretation of the rules as published as of mid-March 2021. These resources in no way are meant to direct provider coding toward a particular level of service or away from appropriate documentation of a visit. All members should consult with their own Coding and Legal experts for formal advice or recommendations as needed.
DeInda Castellano, E/M Coding Task Force, Stacy Calvaruso
Urgent Care Association