Message From Your Region 8 Representatives | January 2019

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  • January 24, 2019
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We are excited for 2019 CMS policy changes and encourage coders, auditors and practice managers to work with medical providers to best accommodate the new changes.

Mary Wood and Michael Warner | Region 8 – West

We realize that these new policies do not have exact requirements. For example, we could debate how a provider can demonstrate focus on what has changed. To answer these questions, we reference the words of CMS Administrator Seema Verma, who seeks “common sense solutions” to “simplify documentation and billing.” If you cannot cite a specific way to implement an aspect of the new policies, use common sense to guide you. As an AAPC member and a certified professional, you have the skillset to lead your organization as CMS seeks to improve documentation and coding.
We encourage you to download new 2019 and 2021 CMS policy changes in the Federal Register. Look at the pages we reference and read the words authored by CMS. When you teach and interact with others about these new CMS policies, use the Federal Register as a reference whenever possible.
We delivered a template use/abuse presentation at the AAPC regional conference in Anaheim, California (September 2018) and we will give an update of the presentation at Healthcon in Las Vegas in April 2019. We encourage you to attend Healthcon and hope to further discuss how to incorporate new policy changes.
We wish all of you a Happy New Year! Read our individual thoughts on CMS’ new policy for health record documentation and scoring below.
Mike and Mary
Michael Warner, DO, CPC, CPCO, CPMA, AAPC Fellow
For 2019, I’m impressed by the new CMS policy allowing ancillary staff members and patients to document the history in the health record (Federal Register November 23, 2018 p. 59635). Patients already have a federal right to request to amend the record per the Standards of Privacy of Individually Identifiable Health Information of 2001, also known as the HIPAA Privacy Rule. This option is not well known by patients or providers. CMS’ new rule makes it that patients can author and document the history.
I have experience with patients authoring the history in the health record. I published clinical research in 2017 studying the patient experience when the history is authored by the patient ( The concept of allowing the patient to author the history may sound strange, but it is a real game changer for medical practice workflow that can improve health record integrity/accuracy.
Medical providers, rushed for time and overwhelmed with clerical duties often feel obligated to populate health records with generic template information. This type of information satisfies billing and coding requirements, but fails to capture the patient’s story and experience with disease. When details in templates are not accurate, health records then contain misleading information that can misguide providers when establishing diagnoses and developing treatment plans. This can result in inappropriate treatment and missed diagnoses. When the patient authors the history, the story is accurate and gives great insight to the patient’s experience with a problem. A well recorded history often makes the diagnosis obvious.
Letting the patient author the history, however, can create problems if the information is not well organized or structured. With our clinical research, we invited patients to complete a PreHistory (PreHx) in advance of the medical encounter. The PreHx is a replica of the near 30 medical interview questions as defined and structured by CMS. Our 2½ page PreHx is available to download for free at non-profit Rather than complete the form in the waiting room or examination room, patients completed their PreHx up to a week in advance of the visit. Since publishing our research, the non-profit created a digital version of the PreHx and offers it for free at
We encourage individuals to seek help from family members, friends and caregivers when completing a PreHx. We suggest patients perform this task at home and in advance of a future medical encounter. We find it takes most patients over 35 minutes to complete their history when they do it the first time. This is not a task that can be effectively performed in a waiting room or examination room. For certain, this cannot be done by a provider in a few minutes. guides individuals through all of the questions within HPI, Status of Chronic Disease, ROS, PFSH with written instructions and video clips. The finished document can be downloaded and/or forwarded to the patient’s email. The non-profit offers this service for free and respects the information as private. Personal information is not sold. The non-profit’s goals are to facilitate patient-provider communication, reduce medical provider clerical burden and improve health record documentation.
Allowing ancillary staff to conduct and report the history is a huge policy change. Previously, per 1997 documentation guidelines, ancillary staff members were restricted to only completing the Review of Systems and Past Family Social History. Now ancillary staff members and patients can work together to document the entire history before the provider enters the room!
Ancillary staff members need to be careful not to replicate a template approach. Satisfying Review of Systems Respiratory with “denies shortness of breath” can fall short if the patient is coughing blood. I envision a best practice of instructing the patient to complete a PreHx, then ancillary staff can assist in getting the information displayed in the health record prior to the provider entering the room.
Allowing patients and ancillary staff to complete and document the history opens the door for improving our healthcare system and improving patient care. Rather than function as stenographers, medical providers can now focus on practicing medicine.
Mary Wood, CPC, CPC-I
I’m impressed by the “focus on what has changed since the last visit” (Federal Register November 23, 2018 p. 59634) as new policy for 2019. Medical providers are often forced to inappropriately use templates because they struggle to populate the encounter note with enough data. The new policy allows a provider to reference History information from previous dates of service and have that information count toward level of service scoring. This measure is intended to reduce unnecessary documentation.
Imagine a medical provider who evaluates an individual in follow up for an injury? At a visit 1-week ago, the provider documented a comprehensive account of how the injury occurred and how the patient felt at the encounter. For today’s note, the provider does not need to re-document all of the History details of how the injury occurred and how the patient felt after the injury. The provider can simply document reference to the previous note, “visit last week reviewed”, and then document any changes from the patient’s prior History or Histories.
Referencing information from previous dates of service creates a new task for medical providers. Just as a provider will now need to acknowledge a History that was recorded by the patient and/or ancillary staff, providers now need to effectively reference information already documented in the health record. In some cases, “reviewed last office note” may be enough. In other cases, the provider will need to be more specific and document the specific date of service. Some situations may arise where the provider needs to briefly summarize what happened with a few words as part of the reference.
When a provider references previous encounter note(s), it creates new challenges for medical coders and auditors. Prior to 2019, Evaluation & Management scoring was based on documentation on the date of service. With new CMS policy, coders/auditors must count information in previous documentation as referenced by the provider. It is critical that coders/auditors work closely with providers to best accommodate the new policy.
“Focus on what has changed” policy prepares us for 2021 when CMS will allow documentation to be based only on Medical Decision Making (MDM). Starting 2021, documentation of the History will be optional. This makes sense since the patient and/or ancillary staff can record the History. For 2021, documentation of the Examination will also be optional. This makes sense because we want providers documenting pertinent findings.
Focusing on “what has changed since the last visit” should reduce misuse of templates. When a provider enters a 9-page template into the health record, it fulfills scoring requirements but often adds information that does not correctly match the patient’s story. I’m sure you have seen medical records that conflict information in the same note. For example, the patient may have a chief complaint of “shortness of breath”, yet Review of Systems states “no shortness of breath.”
I’m impressed by “focus on what has changed since the last visit” because it creates a new mindset for the health record. Hopefully, health record documentation will shift from template use to recording what is pertinent to the patient and their presentation.

Alex McKinley

About Has 111 Posts

Alex McKinley is AAPC’s senior marketing communications manager. Prior to his work at AAPC he worked in the tax and accounting industry. He received his bachelor's degree in Mass Communications (Public Relations Emphasis) from the University of Utah.

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