Featured Article from EDPMA Member Newsletter

Assessing the Risks and Rewards of CMS Rule to Reduce E/M Documentation Burden by Eliminating Re-documentation for Chief Complaint and History

By Dr. Jason Adler, Brault VP of Practice Improvement
& Juli Forde, Principal, Rev4ward, LLC

Article Featured in EDPMA Member Newsletter (March 2019)

As part of the Patients Over Paperwork Initiative, the Centers for Medicare and Medicaid Services (CMS) at the beginning of 2019 implemented rules aimed at reducing the E/M documentation burden. The rules were focused on office and outpatient Evaluation & Management (E/M) visits. In response to a request for feedback on whether to extend the policies beyond the office and outpatient E/M codes set to the emergency department (ED) E/M code set, in the calendar year (CY) 2019 Medicare Physician Fee Schedule final rule, CMS stated, “[W]e are taking a step-wise approach and limiting our policy proposals this year to the office/outpatient E/M code set . . . We may consider expanding our efforts more broadly to additional sections of the E/M visit code set in future years.” So, while the ED E/M itself is not included in new documentation requirements, many Emergency Medicine clinicians also practice in settings where the office/outpatient visit CPT codes (CPT 99201 – 99205; and CPT 99211 – 99215) are used.

For the office/outpatient E/M visit code sets (CPT 99201 – 99205; and CPT 99211 – 99215), beginning on January 1, 2019, CMS began accepting history elements documented elsewhere in the medical record, including if entered by ancillary staff or if personally performed by the beneficiary. According to a CMS FAQ, this 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.” The goal is to reduce the need to re-document elements in the record already stated by ancillary staff or beneficiary.

Previously, the billing clinician could reference the ROS and PFSH from others but had to personally document the CC and HPI. Under the new provisions, the billing clinician may review notes already documented in the chart, update or supplement as needed, indicate an acknowledgement of their review and verification of that information in the record and rely on all of that information for the CC, HPI, ROS and PFSH. In other words, the billing clinician can use a nurse’s notes for the HPI and not re-document what has already been documented.

The intent appears to allow the clinician to focus on generating a more meaningful medical record without having to worry about previous documentation requirements that are founded on counting history elements. These element requirements still exist and must be fulfilled somewhere in the documentation; however, the clinician need not re-document what other members of the treatment team have already included, ideally resulting in less repetition, less time at the computer, and more time for the clinician to be patient-focused.

While the rationale driving the new policy seems well-intended, there remain questions about how the new rules will work in practice and whether it will result in real burden reduction.

  • What will this mean for the overall quality of the chart? Medical experts often say that a good history and physical will get you to the right treatment plan and diagnoses 85% of the time. The new rule only addresses the documentation requirement. Good quality care involves obtaining a good quality history.
  • Will this policy create a gap from what happens at the bedside to what is captured in the record? The HPI is an opportunity to investigate the patient’s story, using a series of questions that explore a working differential, identifying key pertinent negatives and positives. Documenting the HPI puts into words the complex mental work the clinician must go through to properly care for the patient. Will the changing requirements dilute the power of well written HPI or will it really save time and allow the clinician to spend more time with the patient?
  • Will this change affect the legal exposure in case of a poor outcome? The elements and requirements are not changing, but how those elements are documented is changing. Part of the requirement is to review and verify the documentation of ancillary staff. When the clinician puts the stamp “I’ve read and agree with nursing notes,” it is important that the information has been reviewed and verified. This means that the clinician is agreeing to these notes. How much extra time will it take reading the entire record that the clinician is ultimately responsible for compared to the time saved by addressing a few less History items?
  • Does your coding vendor get the entire medical record? You cannot incorporate ancillary notes to fulfill the History elements for coding if those notes are not part of the data feed. This is certainly something that requires follow up with your vendor.
  • Will private payors follow suit? While frequently private payors follow CMS documentation requirements, to the best of these authors’ knowledge, private payors have not published new guidelines that they will align with the January 1 start date of the new CMS rules. This may create difficulties when different payors have different documentation requirements.

Ideally, a well-written medical record is one that accurately captures the encounter, the cognitive work the clinician puts in toward caring for their patients including the background thought process and ‘work intensity.’ A well-written medical record accurately communicates a patient’s condition and treatment to other clinicians, reduces the risk of malpractice, allows for accurate coding, and reflects the high quality work that clinicians perform daily.

We applaud CMS for their efforts to reduce the documentation burden, but the real world effect remains unknown. As CMS directly states in the CY 2019 MPFS final rule, “We note that this policy to simplify and reduce redundancy in documentation is optional for practitioners, and they may choose to continue the current process of entering, re-entering and bringing forward information.” It is important for physicians to consider the potential impacts before taking advantage of the new flexibility being provided under these rules. Before embarking on new internal documentation policies, the full scope of impact should be considered. Consult with your revenue cycle team and medical malpractice experts to determine the best path for moving forward.

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