3 Reasons “Less is More” in Hospital Charting

For decades, healthcare providers have voiced their issues with the growing amount of data entry required for Evaluation and Management (E/M) visits.

Some have even complained about spending twice as much time on the documentation process related to caring for patients. For the first time in almost 30 years, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) have finally made significant changes to the documentation requirements for the coding and billing of E/M codes. These new documentation and hospital billing guidelines, which took effect on January 1, 2021, will reduce the administrative burden on outpatient office visits by requiring less documentation from physicians. 

At Coronis Health, we understand that by simplifying and streamlining your hospital medical billing, coding, and revenue process, you will not only cultivate financial success but establish better patient care as well. Comprising top medical billers in the country pooling their global resources, we can bring customers the best in medical billing and revenue cycle management. We can offer high-touch relationships and solutions tailored to your needs.

E/M Changes Could Result in Less Required Documentation

The new guidelines aim to simplify the way physicians bill Medicare for E/M visits. “Physicians spend a huge amount of time meeting burdensome documentation requirements during patient interactions, which takes time away from patients and contributes significantly to burnout and professional dissatisfaction,” said AMA President Patrice A. Harris, MD, MA. “Our aim is to reduce excessive documentation burden and provide physicians more time with patients, not paperwork.” And most providers would agree that less documentation may translate to increased productivity. Here are three reasons why less documentation may benefit your facility:

1. Specific Notes Keep Focus on Patient Needs 

Changes in E/M codes will benefit any physician’s note-taking process. Physicians no longer need to keep track of everything discussed during a patient’s visit but simply focus on what the patient is seeking treatment for. This change means more precise and more concise notes that the physician can easily reference when needed. And since the history and physical examination elements will no longer be factored into the office/outpatient E/M code selection, this will allow providers to decide how much pertinent history and examination should be documented to allow for a “medically appropriate history and/or examination.” 

“The whole point was to have people, not document stuff that was not necessary, not relevant to the clinical management of the patient,” according to Dr. Peter Hollmann, a former chair of the CPT Editorial Panel and current lead of an E/M workgroup for the AMA.

2. Excessive Documentation Leads to Physician Burnout

A survey from Medscape looked into provider well-being and asked physicians about their feelings on burnout and depression. When asked what was contributing to their burnout, 56% cited too many bureaucratic tasks like charting and paperwork, and 24% said the increasing computerization of healthcare (EHRs) contributed to their burnout. Another study published in the Journal of the American Medical Informatics Association that examined the impact of information technology on stress and burnout found that physicians commonly experience stress by physicians who use EHRs.

Therefore, by streamlining documentation, simplifying billing in hospitals, and lessening the amount of data entry required, not only will providers get to spend more time on direct patient care, but they can lower their stress levels too.

3. Clear Documentation Ensures Accurate Hospital Medical Billing

Accurate medical billing drives the business of healthcare, and the foundation of accurate medical billing is clear and complete documentation. While physicians train to document the services they perform, the medical reimbursement industry is continually evolving, requiring strict documentation standards. Having an experienced documentation professional who has the knowledge and skills for medical coding and billing on your team, therefore, can be a considerable asset and time-saver. 

How Coronis Health Can Ease the Pressure of Your Hospital Billing Services

The changes made on the coding of E/M visits intend to reduce documentation, making billing in hospitals more efficient and giving physicians more time to focus on patient care. However, it also requires you to reassess your documentation system in general.

With more than 100 years of combined experience in hospital billing services, Coronis Health has been assisting healthcare facilities to adapt to changing regulatory guidelines for a very long time. Not only do we stay updated with the latest CMS announcements and hospital billing guidelines, but we remain fully integrated with the newest software so we can input coding instantly and execute collections fast and efficiently. We understand that no matter how regulations and requirements change, documentation can be a burden, no matter your facility size. While we make sure you are 100% compliant, we can also help lighten your load by handling your hospital medical billing and coding responsibilities. We are also 100% transparent, so you will receive valuable facility reporting, allowing you to stay up to date and have access to all your information at all times.

Schedule An Assessment With Coronis Health

Stay focused on patients, not the paperwork. When you select Coronis Health’s medical billing and coding services, you gain a committed partner to your facility’s success. Using industry-leading technology combined with high-touch relationship building, Coronis Health allows you to focus on patient care, accelerate your revenue cycle, and maintain financial independence. To learn more about our hospital billing services, contact Coronis Health today, or request a free financial checkup.

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