Patients Over Paperwork Initiative Focuses on Reducing E/M Red Tape
New documentation guidelines will change how you code and audit evaluation and management services.
In response to an executive order, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma announced the Patients Over Paperwork initiative, which focuses on reducing administrative burdens placed on clinicians while improving care coordination, health outcomes, and patients’ ability to make decisions about their own care. Keeping an eye on these changes, and what they mean for coding and auditing, is essential if you are to remain relevant in the workplace.
Reducing E/M Documentation Burdens
With the announcement of this initiative and its inclusion in the 2019 Medicare Physician Fee Schedule (MPFS) final rule, the coding community is seeing historic changes to the evaluation and management (E/M) codes.
There are two action items in the initiative already influencing how practitioners are documenting:
- Ensuring that medical record documentation supports the quality care being provided; and
- Cutting administrative red tape linked to E/M documentation and claims payment.
Other changes won’t be recognized for the next year or two, such as anticipated structural and valuation changes to the CPT® codes.
E/M Documentation Guidelines
New guidelines pertaining to patient history for E/M services will make a difference in how you code and audit these medical claims. In a fact sheet, published Nov. 1, 2018, CMS addresses the redundancy of the current documentation criteria:
For established patients visits, 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.
Additionally, we are clarifying that for E/M office/outpatient visits, for new and established patients for 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.
Practitioners must still review prior data, update as necessary, and indicate in the medical record they had done so; and they must still conduct clinically relevant and medically necessary elements of history and physical exam, and conform to the general principles of the 1995 and 1997 Documentation Guidelines for E/M Services. Practitioners, however, do not need to re-record these elements (or parts thereof) if there is evidence that the practitioner reviewed and updated the previous information.
The chief complaint (CC), review of systems (ROS), and past family social history (PFSH) may be listed as separate elements of the history or they may be included in the description of the history of present illness (HPI) — in a subjective, objective, assessment and plan (SOAP) format, for instance.
What About HPI?
For years we have audited based on the clinician being responsible for HPI element documentation, but recent clarification from CMS changes the outlook on this particular element.
The difference between what the guidance was and how it changed this year is indicated below:
- 2018 – 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. (Medicare Learning Network, Evaluation and Management Services Guide, August 2017, pg. 10).
- 2019 – For new and established patients 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. (emphasis added to “Calendar Year (CY) 2019 Medicare Physician Fee Schedule (PFS) Final Rule” slides 8 and 9).
CMS Takes a Position
CMS clarifies their position in a CMS Evaluation and Management (E/M) Visit Frequently Asked Questions (FAQ) Physician Fee Schedule (PFS), published Nov. 26, 2018:
What parts of the history can be documented by ancillary staff or the beneficiary starting in CY 2019?
The CY 2019 PFS final rule expanded current policy for office/outpatient E/M visits starting January 1, 2019 to provide that any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the beneficiary does not need to be re-documented by the billing practitioner. Instead, when the information is already documented, the billing practitioner can review the information, update or supplement it as necessary, and indicate in the medical record that he or she has done so. This is an optional approach for the billing practitioner, and applies to the chief complaint (CC) and any other part of the history (History of Present Illness (HPI), Past Family Social History (PFSH), or Review of Systems (ROS)) for new and established office/outpatient E/M visits. To clarify terminology, we are using the term “history” broadly in the same way that the 1995 and 1997 E/M documentation guidelines use this term in describing the CC, ROS and PFSH as “components of history that can be listed separately or included in the description of HPI.” This policy does not address (and we believe never has addressed) who can independently take/perform histories or what part(s) of history they can take, but rather addresses who can document information included in a history and what supplemental documentation should be provided by the billing practitioner if someone else has already recorded the information in the medical record.
Changing the criteria should make things easier, but practitioners must still be sure to document relevant clinical information that influences patient care.
Take Your Own Position
We have educated our clinicians for years to document HPI. My advice is to meet with clinical and management staff and determine if your practice will adopt this more relaxed way of documenting E/M services.
For 2019, documentation requirements of this element have been relaxed, but the guidelines for choosing a level of care have not changed, yet. This is a good time to review your audit criteria and make any necessary adjustments to your processes and decision-making.
Stay tuned as we continue through this E/M journey!
About the contributor:
Ronda K. Ash, CPC, CPMA, CHC, CHCA, is the president of RKAsh Consulting Associates, Inc., a practice management consulting firm. She has been certified by the AAPC since 1996 and is a nationally recognized educator and coding expert. Ash’s expertise includes compliance, auditing, billing operations, and medical coding. She is a graduate of Northwood University with a Bachelor of Administration and the vice president of the Palm Beach County, Fla., local chapter.
CMS Newsroom, Fact Sheet Nov. 1, 2018: “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019:” www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year
CMS FAQ. Evaluation and Management (E/M) Visit Frequently Asked Questions (FAQs) Physician Fee Schedule (PFS). Nov. 26, 2018: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/E-M-Visit-FAQs-PFS.pdf
CMS, Calendar Year (CY) 2019 Medicare Physician Fee Schedule (PFS) Final Rule’ slide 8 and 9: www.cms.gov/About-CMS/Story-Page/CY-19-PFS-Final-Rule-PPT.pdf
Medicare Learning Network, Evaluation and Management Services, August 2017, page 10: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf