On November 1, 2018, the Centers for Medicare & Medicaid (CMS) issued Final Policy changes to the 2019 Medicare Physician Fee Schedule (PFS). While the controversial and sweeping change for how physicians bill Medicare for Evaluation and Management (E/M) has been delayed until 2021, other changes will take place beginning in January.

In an effort to streamline E/M payment and reduce clinician burden, CMS is finalizing the following policies beginning for dates of service in 2019 (cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year):

• Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit;
• For established patient office/outpatient visits, 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.  Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
• 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; and
• Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians.

While any reduction in time-consuming documentation policies are welcome, the above changes do create some lingering questions. For example, what is “the defined list of required elements” that practitioners do not need to re-record from the last visit? Is CMS referring to those elements of History, or Exam…or maybe both? Hopefully CMS will issue clarification over the next couple of months.

How Paragon Business Advisors (PBA) can help…

Let PBA take a look at your current E/M coding and documentation patterns. By taking a simple snapshot of your coding patterns and benchmarking against specialty norms, we can identify if revenue opportunity exists for your practice. In addition, a small review of practice documentation can highlight what you are doing well and what areas may need some improvement. Getting your existing documentation in order, prior to upcoming rule changes, will put you ahead of the game. Let PBA help!

1. Source: CMS.gov