Carol Hoppe MedLucid Solutions

The “Patients over Paperwork” initiative of the Centers for Medicare and Medicaid Services (CMS) was designed to streamline administrative tasks placed on physicians so they can focus on patient care.

In its Final Rule, issued Nov. 1, 2018, CMS agreed to:

• Simplify the documentation of history and exam for established patients so that, when relevant information is already contained in the medical record, clinicians can focus their documentation on what has changed since the last visit rather than having to redocument information.
• Clarify that, for both new and established Evaluation and Management (E/M) office visits, a chief complaint or other historical information already entered into the record by ancillary staff or by patients themselves may simply be reviewed and verified rather than re-entered.
• Eliminate the requirement of documenting medical necessity for visits conducted in a patient’s home versus in an office.
• Remove potentially duplicative requirements for certain notations in medical records that may previously have been documented by residents or other members of a medical team.

These changes took effect  Jan. 1. In practical terms, this means physicians no longer have to redocument information already entered by patients, ancillary staff or residents, and information already documented at a previous visit.
 
It is important to recognize, however, that all information used to calculate the level of E/M service must be clearly referenced, reviewed and verified. When information has already been documented for History and Exam components, for example, the billing clinician can review the information with the patient, update or supplement as necessary, and document in the medical record that he or she has done so. 

The exam still needs to be completed. It just doesn’t have to be redocumented if, let’s say, most of the elements are normal. Here is an example: “I have reviewed and agree with the information documented above. Exam is consistent with my previous assessment on 12/30/2018, except for lungs, which are clear on auscultation today.”

Any payor requests for medical records will need to include all referenced documentation, so staff will need to carefully review the documentation before sending medical records for review.
CMS postponed all of its other proposed changes to E/M services for two years. Beginning Jan. 1, 2021, physicians will have these options to code for office and outpatient services:

• Continue using 1995 and/or 1997 guidelines.
• Base the level of services solely on medical decision making (MDM).
• Choose the level based on total time of the visit, not just when 50 percent is spent in counseling and coordination of care.
• Two new bundled codes for Medicare that will combine levels 2 through 4 but that only require the documentation of a level 2 new or established patient visit.

Deciding which method to use will be a challenge at first, but it will be important to use the method that results in the highest reimbursement for the provider.

If you are an ISMA member and need help doing an analysis on the impact to your revenue, please contact ISMA for assistance.