CMS Wants to Revise E/M Documentation Guidelines

CMS Wants to Revise E/M Documentation Guidelines

Among the many provisions detailed within the 2018 Physician Fee Schedule Proposed Rule, released July 13, the Centers for Medicare & Medicaid Services (CMS) acknowledges that the current evaluation and management documentation guidelines create an administrative burden and increased audit risk for providers:

Stakeholders have long maintained that both the 1995 and 1997 guidelines are administratively burdensome and outdated with respect to the practice of medicine, stating that they are too complex, ambiguous, and that they fail to distinguish meaningful differences among code levels. In general, we agree that there may be unnecessary burden with these guidelines and that they are potentially outdated, and believe this is especially true for the requirements for the history and the physical exam.

In response, CMS announced its intention to undertake a multi-year effort—with the input of providers and other stakeholders—to revise the current E/M documentation guidelines. This revision will likely include removal of the history and exam documentation requirements:

We are … specifically seeking comment on whether it would be appropriate to remove our documentation requirements for the history and physical exam for all E/M visits at all levels.
We believe medical decision-making and time are the more significant factors in distinguishing visit levels, and that the need for extended histories and exams is being replaced by population-based screening and intervention, at least for some specialties.… As long as a history and physical exam are documented and generally consistent with complexity of MDM, there may no longer be a need for us to maintain such detailed specifications for what must be performed and documented for the history and physical exam (for example, which and how many body systems are involved).

The full comments can be found beginning on page 374 of the Proposed Rule, as provided in the hyperlink, above. More details are sure to follow.
Comments on the CMS proposal to revise the E/M documentation guidelines are due no later than Sept. 11, and can be submitted by one of four methods:

1. Submit electronic comments on this regulation to Follow the instructions for “submitting a comment.”
2. Mail written comments to:
CMS-1676-P 2
Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
P.O. Box 8016
Baltimore, MD 21244-8013.
Allow sufficient time for mailed comments to be received before the close of the comment period.
3. By express or overnight mail. You may send written comments to:
Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850.
4. Deliver (by hand or courier) written comments before the close of the comment period to:
Centers for Medicare & Medicaid Services, Department of Health and Human Services,
Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW., Washington, DC 20201

When commenting, refer to file code CMS-1676-P.

Evaluation and Management – CEMC

John Verhovshek
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About Has 569 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

25 Responses to “CMS Wants to Revise E/M Documentation Guidelines”

  1. sharlia says:

    that is very true and with that being said i have a question for an e/m code for cigna insurance is it ok to code a 99243 with a 92567?

  2. Brad Ericson says:

    Hi Sharlia,
    I bet someone out on the Member Forum might have an answer to your question.

  3. Jamie says:

    This couldn’t be more true. With the exceptional transitions in healthcare, having such outdated guidelines produce many problems for providers and time consuming processes that are not necessary for patient care. Please pass this!

  4. Amy says:

    This would be great! I have seen so many 99215 and 99214 based on history and exam.

  5. Sara Bivens CPC says:

    Yes 99243-26 and 92567 are billable together and Cigna does accept consult codes.

  6. Sara Bivens CPC says:

    Oops, sorry the modifer should be 25 not 26

  7. Alyssa Norton says:

    Very informative post!! Thanks for Sharing.

  8. fmporth says:

    I know that CMS is auditing the level 99233 daily rounds and that is good. However, you have some doctors that think that every patient they see requires a level 99233 daily round. Can there be more guidelines to these?

  9. Dorothy Firth says:

    I believe HPI and MDM are important components of E&M services.

  10. Lisa Henderson says:

    Good day,
    I have a question in regards to an attestation. What is the normal time frame when attaching an attestation to a fellow’s note by a teaching physician. I thought it was 24-48 hours, or within 7 days. Can someone please shed some light on this question.

  11. Valerie Milot says:

    with EHR’s the proposedchange would be more accurate because most systems are now just a click and a book of information gets dropped into the current encounter

  12. Ruth Muench says:

    CMS is on the right track esp. with time. That is how I see it when reviewing E/M Codes overall. x”s 5

  13. ken says:

    Its a trick. Now that everyone uses EMR having detailed ROS and physical exam is just a few clicks. CMS just looking for ways lower the number of high level visits paid out. 10 years ago if my level 5 notes got audited they would be downcoded. Now since I’m using EMR auditing my charts is futile.

  14. Karantarat Kimyuan says:
    quoted from CMS-1676-P page 376…..”We are also specifically seeking comment on whether it would be appropriate to remove out documentation requirements for the history and physical exam for all E/M visits at all Levels….”
    My comment is: I disagree. “History and Physical exam should also play the significant parts for E/M Leveling”

  15. mzprince2002 says:

    Big mistake. The less they HAVE to do, the less they WILL do

  16. Crystal says:

    I think this is a great idea and long overdue, especially since the implementation of EMR/EHR’s. Let the MDM/time decide the visit.

  17. Marlene Santos says:

    I think this is a great idea. Yes, adjust the documentation requirements. Thank you

  18. Anonymous says:

    There is no standard book for a HCC coder to learn surgery coding…..Nobody

  19. Anne Faulkner, CPC says:

    I agree. Base the code on medical decision making data and time spent with the patient face to face.

  20. Lindsey Langmaid says:

    I agree with that we must keep those component requirements;
    As a Patient and having limited clinical background I would not want a Physician who does not know me to prescribe anything or make a plan without examining my history , genomic and otherwise, and doing an exam. While auditing I see the mess that EHR has already made and how Physicians who are working around “technical” requirements with templates offering no real information, presenting blatant contradictions violates the integrity of the note. I recall a coworker with a Schwanoma who went into surgery and the surgeon removed a lymphnode. She realized it afterwards because she could still “feel it”, why couldn’t he? Did he not examine her over again and again or was he just looking at imaging?. The documentation guidelines reflect the clinical guidelines for good scientific method which started when Lawrence Weed who coined SOAP. The Science of observation and good note keeping allows analysis and experimentation to produce best information and results. The Government is focused on reducing cost/payment, the clinical regulatory agencies are focused on patient safety and the science. The world of reimbursement forgets the underlying purpose of the medical record and equivocates it with the tedium of book keeping. No matter what the Government comes up with regarding payment method, lets keep the pressure on quality, the history and exam are a part of that and we can’t send the Physicians the wrong message about the “necessity” . Personally I can google my symptoms and retrieve multiple prognoses but I go to a Physician for his expertise based on my history and manifestations and expect at treatment plan tailored to my particular needs. I don’t know my own biology and I live with myself, I trust a doctor, I tell him/her intimate details of my life, I expect more than just listen to me and prescribe, I am not at the 10 minute clinic.
    Ask yourself if you trust a doctor who thinks history and exam is a cumbersome process. Would you pay him whether he does it or not? And how do you level the fair fee without? We can’t carve out the clinical expectation from the reimbursement without going toward universal healthcare. Weigh it out carefully.

  21. Yolanda says:

    I totally agree that they need to revise the E/M guidelines. I would even propose that they just have a single set of guidelines. In other words get rid of 1995 and/or 1997. For those of you who do not know this. I would advise you to check your Medicaid fee schedule. They have made a significant drop in pay for certain procedures performed in 21, 22, 23 & 24. For instance we billed 45330 and usually we would get paid $84.10 we are now getting paid $10.61. This would involve your Medicaid HMO’s as well and took place 1.1.2017.

  22. Maryann Palmeter, CPC, CENTC, CPCO says:

    Keep in mind folks that this proposal is only for billing purposes. There are still minimum medical record requirements at the state level and Joint Commission still requires a HISTORY and PHYSICAL at certain times.

  23. lisa fisherCPC says:

    the need to get components of the HPI. I review psych notes and I can’t imagine them trying to prescribe psych meds without knowing what is going on with the consumer. They don’t reference old notes, its all about getting them in and out in 15 minutes and how many can be seen patient care will suffer if they change standards.

  24. Amy says:

    They are looking to remove the requirements, not remove them completely . For coding purposes we would code the E.M. based off MDM and risk, not off of how many ROS did you meet? Oh, you missed one, just click it so I can bill it. I think this is a great idea and would put alot of providers in prospective of how off their coding as been for years.

  25. Marilyn M says:

    Back to the old SOAP note is not a bad idea. And no one said that elements of the history and exam that are relevant don’t have to be documented at all. They just won’t count for payment. This is a bug overhaul. But good. And necessary.