Did you know? CMS finalizes one small E/M change in 2019
As part of its effort to simplify and streamline E/M coding, CMS had proposed to remove “redundancy” in E/M documentation. One such measure proposed as part of the E/M changes now set for 2021 is actually going into effect on Jan. 1, 2019.
Starting in January, CMS will allow providers to omit elements of the history and exam that haven’t changed since the last time a patient was seen. This will apply only to established patient visits. “Practitioners would still review prior data, update as necessary, and indicate in the medical record that they had done so,” CMS explains in the final rule. “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.”
This logic had always applied to the patient’s past/family/social history (PFSH) portion of the E/M note for established patients, as such information was unlikely to change between visits. However, the new policy applies this reasoning to the entire history as well as the exam, making it easier to achieve level 4 and 5 levels of service, which require a detailed (2-6 organ systems, with at least 1 system documented in a detailed fashion) level of exam or a comprehensive (at least 1 bullet from 8 organ systems) level of exam.
If, starting Jan. 1, a physician decides to carry forward elements of the history and exam, CMS does still require documentation that those elements not updated were reviewed and thus not necessary to update. “Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so,” the agency states.
Thus, a simple statement such as “All other elements of history and exam were reviewed and unchanged, except as documented above.” This could be inserted after the history and exam components. While CMS believes this will speed up documentation for established patient visits, it doesn’t require you to change your template. “We note that this policy to simplify and reduce redundancy in documentation is optional for practitioners,” CMS states. “The option to continue current documentation processes may be particularly important for practitioners who lack time to adjust workflows, templates and other aspects of their work by January 1, 2019.”
The original language from CMS can be found in Section I., part 2b of the 2019 final rule at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.
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