New AMA billing guidelines may not yet ease burden of EHR time for many physicians

A new observational study has found that the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) new billing guidelines immediately affected the distribution of evaluation and management (E/M) patient visits but have had no impact on the amount of time providers spend writing notes in the electronic health record (EHR) or the overall length of notes. The findings are published in Annals of Internal Medicine.

Extensive documentation for reimbursement combined with low EHR usability contributes to high rates of physician burnout and job dissatisfaction. To combat this, the AMA and CMS recently made optional the history and physical examination elements of the physician note. 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 each visit.

Researchers from the University of Pennsylvania conducted an observational study of 303,547 advanced practice providers and physicians across 389 organizations. The authors collected provider-level measures of weekly E/M billing and measures of EHR use between September 2020 and April 2021 from the Epic Systems Signal data warehouse. The authors analyzed eight measures of E/M visit volume and seven measures of EHR use to determine factors including the proportion of weekly E/M visits, total weekly new and established E/M patients, total active time per visit spent in the EHR, and EHR documentation length. The authors observed an overall increase in new and established patient E/M visits billed to levels 4 and 5, and a decrease in visits billed at level 3. However, the policy responses across specialties differed, with some specialties demonstrating substantially larger shifts in E/M billing. The authors also observed no overall change in time spent in the EHR or documentation length. According to the authors, their findings suggest that the effects of the policy have thus far been limited to modifications of billing practices, despite the explicit intent to simplify reimbursement and reduce documentation burden. They also note that observing changes in billing practice without meaningful improvement in measures of EHR burden highlights a continued opportunity to identify and scale practices that more directly address salient pain points of EHR usability.

An editorial from the AMA argues that note length and active EHR time is not a perfect proxy of physician burden, and that the reason for a lack of change in active EHR time and note length cannot be known from the study. The author suggests that further studies on the quality of notes, along with qualitative interviews of physicians, will help determine which type of billing is used, whether cognitive burden was reduced, and why documentation time and note length have not yet been affected as intended.