Billing code updates intended to reduce EHR time lead to ‘no meaningful changes’

Despite the intent of the AMA and CMS, updates to frequently used billing codes led to “no meaningful changes” in note length or time spent on electronic health records, researchers wrote.

Healio has repeatedly covered studies and interviewed physicians about the burden of EHRs, which are a major source of burnout.

To alleviate this burden, on Jan. 1, 2021, the AMA and CMS made “specific elements of previously required documentation in the physician note, namely the history and physical examination,” optional, Nate Apathy, PhD, a postdoctoral fellow in health services research at the Perelman School of Medicine, and colleagues wrote in Annals of Internal Medicine.

At the time, AMA and CMS said the changes to evaluation/management (E/M) codes were made so that physicians could spend more time with patients and less time on paperwork, according to the researchers.

“The AMA also streamlined the logic in applying E/M visit codes based on medical decision making to facilitate less ambiguous synthesis of the complexity of problems, complexity of data and risks for complications in a given visit,” they wrote.

Apathy and colleagues conducted an observational retrospective study to assess how AMA’s changes aligned with their intended goals. Their analysis included EHR data from 303,547 health care advanced practice providers from 389 organizations.

The researchers observed a shift in E/M visit use before (September to December 2020) and after (January 2021 to April 2021) the guideline change for frequently used billing codes. They reported that the number of level 3 visits dropped by 2.41 percentage points (95% CI, –2.48 to –2.34) to 38.5% of all E/M visits, a 5.9% relative decrease. The number of level 4 visits rose by 0.89 percentage points (95% CI, 0.82-0.96) to 40.9% of E/M visits, a 2.2% relative increase, while the number of level 5 visits (the highest acuity level) rose by 1.85 percentage points (95% CI, 1.81-1.89) to 10.1% of E/M visits, a 22.6% relative increase.

Other comparisons the researchers noted for each patient visit before and after the billing code changes took effect included:

• a mean increase of 24.37 (95% CI, 21.23-27.51) in characters within clinical notes;
• a mean decrease of 0.06 minute (95% CI, –0.07 to –0.04) in time spent on notes;
• a mean decrease of 0.2 minute (95% CI, –0.23 to –0.17) in time spent on EHR;
• a mean decrease of 0.01 minute (95% CI, –0.01 to 0) in time spent on clinical review; and
• a mean decrease of 0.01 minute (95% CI, –0.02 to 0) in time spent outside scheduled hours.

The researchers also reported that the results varied among high-volume, high-E/M specialties, with primary care experiencing “a less dramatic upward shift” in the distribution of E/M visits, the researchers wrote.

The lack of an “immediate reduction in EHR documentation burden ... underscores longstanding frustrations with competing priorities that often sideline efforts to reduce provider burden,” Apathy and colleagues wrote. “Health care organizations will likely need explicit guidelines and incentives to take a comprehensive approach to measuring and addressing EHR usability.”

In a related editorial, Christine A. Sinsky, MD, AMA’s vice president of professional satisfaction, called the findings “unexpected,” and said that “note length and documentation time are not perfect proxies of burden.

“The cognitive burden of conforming a patient’s history into a complex set of bullet points and counting up organ systems has been eliminated,” she wrote.

According to Sinsky, physicians may not be using the new billing codes out of confusion over the guidelines or because they are hesitant to believe the new codes will provide relief.

“Given the historical complexities of billing by content, many physicians may bill by time, a seemingly simpler approach,” Sinsky wrote, noting that this approach has its pitfalls.

“First, because only the physician’s time counts, billing by time systematically encourages inefficient doctor-does-it-all models of care that ultimately reduce capacity and thus access and continuity. Advanced models of team-based care, with strategic delegation of tasks away from the physician, have been shown to increase capacity and quality, decrease hospitalizations, and reduce cost and burnout,” she wrote. “Second, billing exclusively by time can result in levels of revenue that may perpetuate the mindset that adequate staffing is not affordable in nonprocedural settings.”

Sinsky added that future studies may shed light on “why documentation time and note length have not yet been affected as intended.”

References:

Apathy NC, et al. Ann Intern Med. 2022;doi: doi:10.7326/M21-4402.

Siminsky CA. Ann Intern Med. 2022;doi:10.7326/M22-0355.