Documentation requirements for physician Evaluation & Management (“E/M”) visits have not been updated in 20 years. On November 1, 2018, CMS finalized bold proposals that address provider burnout and to provide clinicians immediate relief from excessive paperwork tied to outdated billing practices.
The revisions also update some policies under Medicare’s Accountable Care Organization program that streamline quality measures to reduce administrative burdens and encourage better health outcomes. These new rules are projected to save clinicians $87 million in reduced administrative costs in 2019 and $843 million over the next decade.
Chief Complaint Documentation
- For new and established patient E/M office and outpatient visits, practitioners need not re-enter the medical record information on the patient’s chief complaint that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.
History Documentation
- For established patient visits:
- Describe any new ROS and/or PFSH information or note there has been no change in the information and reference the date and location of the earlier ROS and/or PFSH.
- The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. Documentation that the physician reviewed the ROS and/or PFSH recorded by ancillary staff must be present; there must be a notation supplementing or confirming the information recorded by others.
- New patient visits: Practitioners need not re-enter a patient’s history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.
Exam
- Established patient E/M office and outpatient visits:
- When relevant information is already contained in the medical record, practitioners are only required to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements.
- Practitioners would still review prior data, update as necessary, and indicate in the medical record that they had done so.
- Practitioners would conduct clinically relevant and medically necessary elements of the physical exam and conform to the general principles of medical record documentation in the 1995 and 1997 guidelines. However, practitioners would not need to re-record these elements (or parts thereof) if there is evidence that the practitioner reviewed and updated the previous information.
- When relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.
