With the new requirements of evaluation and management (E/M) beginning Jan. 1, 2021, we can no longer keep documenting as we always have. So how do you begin making the change? These five steps will guide you on your journey.

Step 1: Determine, at minimum, the top five conditions treated by each physician of the practice.

• Analyze diagnosis productivity report
• Analyze procedural productivity report
• Create a list for physician to review and expand upon

Step 2: As history elements will no longer be counted, ask the physician to convey what history they would ask when a patient presents with identified condition(s).

• Remember there are payer policy requirements that must also be followed. Example: If you're considering punctal occlusion, ask what other methods the patient has tried to improve a dry eye condition.

Step 3: Confirm which quality measures for the Merit-Based Incentive Payment System (MIPS) your practice will keep and how each measure may impact documentation

Step 4: For the above conditions, ask the physician what medically relevant elements of the exam they want the tech to perform. For example, if sensorimotor exam and/or confrontation fields are not relevant for an established patient exam or not needed to continue to perform.

Step 5: Create a fact sheet per condition noted.

• Education is paramount for all ancillary staff so that everyone knows the expectations.
• Remember to educate new staff and have continued education throughout the year to ensure consistency.

For a comprehensive review of all the 2021 E/M documentation guidelines, explore Conquering New E/M Documentation Guidelines for Ophthalmology and visit aao.org/em.