When clinical documentation gets overrun with auto-populated data, it’s time to redirect technology to better serve our patients. Medical providers will no longer be required to document the history/medical interview during outpatient/office services in health records starting Jan. 1, 2021, per the 2019 Medicare Physician Fee Schedule (MPFS) final rule. This new policy is supported ...
In Coding
Feb 1st, 2019
As a required component of any E/M service, the history of present illness (HPI) is a chronological description of the development of the patient’s present illness, from the first sign or symptom, or previous encounter, to the present. Both the 1995 and 1997 Evaluation and Management Documentation Guidelines quantify the HPI by: Location: Patient statements regarding ...
In CMS
Aug 8th, 2018
During a July 18, 2018 CMS Twitter™ podcast, CMS National Coordinator for Health Information Technology, Donald Rucker, M.D. defended the new CMS 2019 proposal to make documentation of the History optional for health records. He was asked, “In light of technology’s thirst for data to identify best practices and construct predictive algorithms, is it possible ...
In Coding
Oct 3rd, 2016
Nothing in either the 1995 or 1997 E/M documentation guidelines state that you cannot count a single documented item in both the history and review of systems (ROS)—so called “double dipping.” Nothing in AMA/CPT® or Centers for Medicare & Medicaid (CMS) guidelines says so, either. If an item is clearly documented, you may count it ...
In Billing
Feb 19th, 2016
When billing Medicare, a provider may use either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management (E/M) CPT or HCPCS Level II code. For services performed on or after September 10, 2013, however, physicians may use the 1997 documentation guidelines for an extended history of present illness ...