CMS changes to documentation requirements for E/M services 

March 14, 2019
While there will be no changes to the codes reported or how E/M services are paid in 2019 and 2020, there are changes to what doctors need to document to support reporting of each E/M service.
CMS Medicaid Medicare

Excerpted from page 44 of the March 2019 edition of AOA Focus.

The Centers for Medicare & Medicaid Services (CMS) has made changes to documentation requirements for evaluation and management services (E/M) for 2019. Doctors of optometry who report E/M services for Medicare patients should be aware of these changes.

The AOA advocated for speci­fic documentation changes for 2019 that would reduce unnecessary and repetitive patient health record documentation. CMS has been responsive to these concerns and has made changes for 2019 and 2020.

While there will be no changes to the codes reported or how E/M services are paid in 2019 and 2020, there are changes to what doctors need to document to support reporting of each E/M service. Doctors should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare.

For calendar year 2019 and beyond, CMS has finalized the following policies:

Established patient documentation

CMS has indicated, "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."

Home visits

CMS has eliminated the requirement to document the medical necessity of a home visit in lieu of an office visit.

Documentation by ancillary staff­ and residents

  • For E/M office/outpatient visits, for new and established patients for visits, practitioners are not required to re-enter information in the medical record on the patient's chief complaint and history if it has already been entered by ancillary staff. The practitioner should indicate in the medical record that he/she reviewed and veri­fied the information.
  • CMS has removed the requirement for notations in medical records that 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.

CMS intends to make additional adjustments for payment, coding and other documentation changes related to E/M services in 2021. The AOA will continue to advocate for policies that are fair and take into account the role of primary eye care. Look for updates in future issues of AOA Focus.

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