Inpatient: New January 2023 E&M Documentation and Coding Changes
- Evaluation and Management (E&M) documentation and coding is the system in which physicians and other healthcare professionals represent their services for purposes of billing.
- Historically, E&M code selection was based on either key components of history, physical and medical decision making, or face-to-face time.
- Beginning in January 2023, for both inpatient work and consultations (outpatient and inpatient), E&M codes will be selected based only on medical decision making or total time on the date of service.
- Earn CME by attending one of four informational webinars live [sessions will also be recorded]:
- November 29, 2022, 5:30p.m. - 6:30 p.m. [complete]
- December 8, 2022, 7:00 a.m. – 8:00 p.m. [complete]
- December 15, 2022, 12:00 p.m. – 1:00 p.m. [complete]
- December 29, 2022, 5:30 p.m. – 6:30 p.m.
- Learn more information and about educational opportunities here.
Inpatient: Periprocedure Code Status
- The new health system policy regarding periprocedure code status, and the Epic build needed to support this workflow, are available.
- Ask a patient about their goals of care regarding code status during a procedure if:
- They have an existing limited code status order or who express a preference regarding life-sustaining treatments.
- They are having a procedure that involves moderate/deep sedation or anesthesia, then the new Epic workflow should be followed to document their wishes.
- Review the tip sheet here and the 3 min Periprocedure Code Status Video/demo for more information.
Inpatient & Ambulatory: MyChart Medical Record Instant Download - [Effective January 5, 2023]
- Adolescents and Proxies of adolescents will have access to request a PDF of their medical record, like other JHM MyChart users.
- The PDF document will be available to the patient and/or proxy to download for approximately 30 days.
- Patients and proxies can still request paper records through Health Information Management [HIM].
- Clinicians still have access to block notes, results, and flowsheets in accordance with the 21st Century Cures Act.
- Review the blog post here and the MyChart – Guiding Patients through Health Record Requests tip sheet.
Ambulatory: Level of Service [LOS] Changes – [Effective January 1, 2023]
- The AMA’s Medical Decision Making criteria include two new options for Low Number or Complexity of Problems Addressed at the Encounter.
- These new options are added to the previous Level 3 Problems Addressed in the Outpatient Level of Service Calculator:
- 2 or more self-limited or minor problems
- 1 stable chronic illness
- 1 acute, uncomplicated illness or injury
- 1 stable, acute illness
- 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care
- Review the blog post here.
Ambulatory: Expected Patient from Ambulatory to ED Workflow [Effective – January 19, 2023]
- Completion of a new Epic form, eliminating the need for direct provider telephone communication, automatically places the expected ED patient on the ED status board, and is available for all ambulatory clinicians in all adult and pediatric ambulatory locations.
- Review the blog post here and the ED Admission – Expected Patient Workflow from Ambulatory to ED tip sheet for more information.
Ambulatory: Updates to the ESS-6 Patient Safety Screening Flowsheet
- To more accurately reflect a patient’s suicide risk the patient is categorized as a ”high risk” if they have one or both of the following:
- A current attempt of suicide.
- A plan and intent for suicide.
- Review the blog post here.
Ambulatory: Telemedicine Hot Topics – States of Emergency Telehealth Service Updates
- The Public Health Emergency [PHE] has been extended 90 days [through at least January 11, 2023]
- The Office of Telemedicine launched new training portal for quick access to training videos, tip sheets, and other resources to assist providers.
- Refer to legal FAQs for information related to individual state waivers and licensing requirements.
- Direct general questions to JHM Telemedicine or legal-specific questions to Telemedicine Legal.
-Juliet Allen, MSN, RN, Business Solutions Analyst, Health IT Optimization & User Wellbeing
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