Implementing the 2021 Guidelines for Office and Outpatient Visits

Description

The providers and staff involved in billing, coding, and documentation all need to understand the new guidelines to ensure the documentation supports the services being reported to the insurance companies. If the documentation does not support the services, and the provider is audited, there may be fees and penalties involved due to improper coding. These new guidelines make documentation easier as they are more relevant to medicine and the treating of patients today, and should reduce the time spent documenting irrelevant elements to the care of the patient.

In order for a medical provider to be compliant with the documentation and levels of service involved in office and outpatient visits, they must follow the current guidelines for documentation. Beginning January 1, 2021 there are new guidelines being implemented for all medical claims, regardless of insurance. These guidelines are published in the CPT® manual with the explanation of what they are and how to apply them. There are new ways of determining the level of service on the documentation to support time or medical decision making. Providers may have to change their documentation and templates based on these new guidelines and will need to know what is required.