• Vidya Baliga

2020 CMS Medical Record Changes

Practicefirst would like to notify our clients of important changes as outlined by CMS for CY 2020 regarding Medical Record Documentation.

As per CMS MLN Matters MM11560:

Medical Record Documentation:

CMS is finalizing, for CY 2020, a proposal to reduce burden by implementing a broadened general principle beyond teaching physicians that will allow:

  1. All physicians,

  2. Physician Assistants (PA’s),

  3. Nurse Practitioners (NP’s), Clinical Nurse Specialists (CNS’s), Certified Nurse-Midwives (CNM’s), and Certified Registered Nurse Anesthetists (CRNA’s), each of whom are recognized as Advanced Practice Registered Nurses (APRN’s),

to review and verify (sign/date) documentation in medical records without having to re-document notes the record already includes.

This principle applies to all Medicare-covered professional services that each of these professional disciplines furnish, and that are paid under the MPFS.

In addition to physicians, residents, nurses, and medical students, this provision includes PA and APRN students or other members of the medical teams, as individuals who are allowed to make notes in a patient’s medical record, and that are reviewed and verified by physicians, PA’s and APRN’s.

Scope of Practice

For CY 2020, CMS is finalizing the “Physician Supervision for Physician Assistant (PA) Services” proposal, implementing CMS' reinterpretation of Medicare law that requires physician supervision for PA’s professional services.

Accordingly, Federal regulations at 42 CFR 410.74 (a)(2) require that PA’s must furnish their professional services in accordance with State law, and State scope of practice rules for PA’s that are specific for the State in which the services are furnished to the extent that those rules describe the required relationship between physicians and PA’s, including its collaborative nature, and describe a form of supervision for Medicare’s purposes.

For States with no explicit State law and guidance regarding physician supervisions of PA’s, physician supervision is a process with one or more physicians to supervise the delivery of their healthcare services. Such physician supervision is evidenced by documenting the PA’s scope of practice and indicating the working relationships the PA has with the supervising physicians when furnishing professional services, with any required documentation of PA supervision maintained at the practice level, instead of in the medical record for each patient.

Click here to view the above MLN Matters MM11560.

The Medical Record Documentation portion begins on page 2 of 6.


For Coding questions, please contact our Coding Supervisors, Vidya Baliga at vidyab@pracfirst.com and Kelly Cole at kellyc@pracfirst.com or at 716-389-3262.

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