ACOEM Tip Sheet on Coding Evaluation and Management Encounters for Workers’ Compensation

In 2021, the Centers for Medicare and Medicaid Services (CMS) implemented new rules for coding outpatient Evaluation and Management (E&M) encounters. Under the new rules, providers can now use time-based or medical decision making (MDM) based coding for encounters that follow CMS rules. Many, but not all, workers’ compensation (WC) insurance providers have also adopted the new rules. Therefore, ACOEM developed this tip sheet to assist providers of WC care in appropriately documenting care using the new coding model. Recognizing that WC care differs from personal medical care in several respects, ACOEM proposes in this tip sheet some additions to the documentation examples for time-based coding offered by CMS. ACOEM believes that time-based coding, with appropriate documentation in the patient’s health record, is a better alternative than MDM-based coding for WC encounters, because it provides the most flexibility.

 Note that documentation of quality care in WC encounters should address:
  • Causation: Mechanism of injury; causation; relationship of work factors to the presenting condition
  • Function: Functional impact of the condition and implications for work; functional outcomes in subsequent visits
  • Work Disability Risk: Risk factors for prolonged work disability and plan for mitigation if present
  • Work Planning: Return to work planning, involving other parties (employer, WC case managers) as needed
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