E&m documentaiton updates 2019

Elizabethchris

Networker
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In reference to "required elements" below, is that the 3 KEY components (History, exam, and MDM)? Or just the history and exam?

For established patient office/outpatient visits, when relevant information is already contained in the medical record, providers 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. Practitioners should still review prior data, update as necessary
 

MnTwins29

True Blue
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I found this example statement that a physician might say when reviewing documentation by ancillary staff on our MAC (NGS) site

Example: DOS xx/xx/2019 – I have reviewed the HPI dated xx/xx/201x and there are no significant interval history changes. Physical examination remains unchanged. Patient will continue current medication regiment.

Since the medication would fall under MDM, to me that means that MDM, or at least some elements, may fall under this.

Something I also tell our physicians is that this is OPTIONAL - if the MD doesn't feel comfortable with this, he or she may always document these items themselves. Some of our doctors still prefer to do that.
 

Elizabethchris

Networker
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I found this example statement that a physician might say when reviewing documentation by ancillary staff on our MAC (NGS) site

Example: DOS xx/xx/2019 – I have reviewed the HPI dated xx/xx/201x and there are no significant interval history changes. Physical examination remains unchanged. Patient will continue current medication regiment.

Since the medication would fall under MDM, to me that means that MDM, or at least some elements, may fall under this.

Something I also tell our physicians is that this is OPTIONAL - if the MD doesn't feel comfortable with this, he or she may always document these items themselves. Some of our doctors still prefer to do that.
Thanks so much! This confirms it :)
 
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