CMS Evaluation and Management Office/Outpatient Visit Documentation Changes for 2019

CMS Evaluation and Management Office/Outpatient Visit Documentation Changes for 2019

Per the final rule regarding the CMS (Centers for Medicare & Medicaid Services) evaluation and management (E/M) documentation guideline changes for office/outpatient visits (released November 1, 2018), the following office outpatient visit documentation changes will be implemented January 1, 2019:

History and exam documentation for established patients for E/M office/outpatient visits

The current 1995 and 1997 CMS E/M documentation guidelines allow for a previously obtained ROS (Review of System) and/or PFSH (Past, Family and Social history) of an established patient, in an institutional setting or group practice where providers use a common record, to be reviewed and updated without having to re-record the documentation.

Per the current CMS Evaluation and Management Services Guide:

The review and update may be documented by:

  • describing any new ROS and/or PFSH information or noting there has been no change in the information; and
  • noting the date and location of the earlier ROS and/or PFSH.

Effective January 1, 2019 CMS will expand on this, and include exam documentation. Per the final rule, CMS states:

When relevant information is already contained in the medical record, practitioners would only be 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 such as review of a specified number of systems and family/social history.

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 history and 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.

Accordingly, 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.

Chief complaint and history documentation for new and established patients for E/M office/outpatient visits

The current 1995 and 1997 CMS E/M documentation guidelines allow for the use of ROS and/or PFSH documentation that has been recorded on a form completed by the ancillary staff and/or the patient. Per the current CMS Evaluation and Management Services Guide:

The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

Effective January 1, 2019 CMS will allow the chief complaint and history for a new and established patient that has been entered by the ancillary staff and the patient, to be used by the provider. Per the final rule, CMS states:

For new and establishedpatients for E/M office/outpatient visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and 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.

Note that CMS has stated that these are optional documentation processes for providers, for office outpatient visit documentation.

What does this mean for you?

Check with your RAC and your non-Medicare payers to verify which office outpatient visit documentation guidelines they currently follow, and if they are going to make any changes based on the new CMS guidance, before making any facility-wide changes to your documentation templates. You may find that they may not accept the new CMS redundant data recording documentation guidelines, which could open you up to documentation deficiencies with your RAC and/or your non-Medicare payer chart reviews.

Should you choose to apply the CMS redundant data recording documentation guidelines, you will need to educate your nurses, providers, scribes, coders, auditors, and anyone else in your facility who participates with your documentation processes, on how to apply these new guidelines. You will need to work with your electronic medical record (EMR) vendor, nurses, providers, and scribes to ensure that your EMR templates can effectively and efficiently accommodate these new documentation requirements.

Resources

CY 2019 Physician Fee Schedule and Quality Payment Program final rule

Evaluation and Management – CEMC

Department of Health and Human Services Centers for Medicare and Medicaid Services Evaluation and Management Services guide

Jessica Schlapper-Spiering

Jessica Schlapper-Spiering, CPC, CEDC, CCS is the owner of Complete Physician Services, LLC and has over 22 years of experience in the healthcare information field as a coder, auditor, educator, and director. Her main areas of focus are Emergency Department coding/auditing, E/M documentation compliance, and ICD 10 CM guideline education.

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Jessica Schlapper-Spiering, CPC, CEDC, CCS is the owner of Complete Physician Services, LLC and has over 22 years of experience in the healthcare information field as a coder, auditor, educator, and director. Her main areas of focus are Emergency Department coding/auditing, E/M documentation compliance, and ICD 10 CM guideline education.

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