By Linda Duckworth, CHC, CPC
Director, Provider Education & Advisory Services
In January 2023, the landscape of Hospital Medicine experienced a significant shift with the introduction of historic coding and documentation changes for Evaluation and Management (E/M) services. Providers welcomed these changes, celebrating the newfound ability to eliminate cumbersome and often meaningless documentation from their initial visits, including history and physicals (H&Ps). However, this reform raises an important question: Have hospitals updated their medical staff bylaws to align with the new E/M guidelines, or are they still operating under the old standards requiring a comprehensive history and exam?
Medical staff bylaws are often meticulously crafted documents that have not seen significant revisions in years. With the recent changes in E/M documentation, hospitalists, and leadership teams must ensure their bylaws are up to date and in sync with current practices.
Understanding the E/M Changes
The AMA’s 2023 updates to E/M coding were designed to reduce the documentation burden on healthcare providers, allowing them to focus more on patient care. One of the most notable changes was removing the need for a comprehensive history and exam. Previously, these elements were often mandated to include an extensive review of systems (typically 10 or more), a family history, and a complete multi-system exam, whether they were pertinent or not. Under the new guidelines, the history and exam must only be “medically appropriate,” giving providers more discretion in what they do and what they document.
The Importance of Bylaw Alignment
Bylaws are the governing documents that outline the expectations, responsibilities, and standards for medical staff within an institution. They often detail the requirements for H&Ps and are rooted in the old E/M guidelines. Providers who document under the new guidelines may inadvertently be out of compliance. This could lead to issues with hospital accreditation organizations, which may still expect adherence to the older, excessive documentation standards.
A Call to Action for Hospital Leadership
Given the potential for misalignment, hospitalists should raise this issue within their institutions and encourage a review of the medical staff bylaws. These bylaws must be examined in the context of the new E/M documentation practices to ensure consistency and legal soundness.
Proactive leadership is key. Instead of waiting for an accreditation surveyor to point out discrepancies or a medicolegal concern to be raised, hospitals should take the initiative to revise their bylaws now. This will not only help to avoid potential conflicts but also ensure that providers can continue to document efficiently and in accordance with the latest standards.
Conclusion: The Need for Continuous Review
Hospitalists and healthcare leaders must collaborate to review and revise these governing documents frequently to ensure they are consistent with current practices and compliant with regulatory requirements and allow the best possible care for their patients.
Learn More About Provider Education
