Revision to E/M Documentation Guidelines
Practicefirst’s March client memo referred to the important revisions that CMS has made to Evaluation and Management
Documentation Guidelines, which are effective January 1, 2019.
** Please note the correction to the third bullet below. The requirement should not include the physical exam. We apologize for the miscommunication.
Highlights of CMS’s revisions include the following:
The requirement to document medical necessity of furnishing visits in the home rather than office will be eliminated.
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. They do not need to 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.
Physicians will no longer be required to re-record elements of history when there is evidence that the information has been reviewed and updated.
Information regarding chief complaint and history can be recorded by ancillary staff or the patient. To document that the physician reviewed the information, there must be a notation confirming the information recorded by others.