With the New Year, changes come to Evaluation & Management (E&M) coding this year and beyond. With simplification to Medicare policies regarding E&M service, we will see a few of these implemented beginning January 1, 2019.

Coding E&M services has always been confusing, and the amount of documentation required to support it degrades the patient experience. With that in mind, the 2019 Medicare Physician Fee Schedule Final Rule cemented some very material and important changes are going to be happening between January 1, 2019 and January 1, 2021.¹ 

What to Know Today

• 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;
• 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.

These changes reduce some of the minutia that did not enhance patient outcomes. Removing the obligation to re-record duplicative information should improve efficiencies and enhance compliance.

More Coming Up

The Centers for Medicare & Medicaid Services will continue to reduce burden by implementing of payment, coding and other documentation changes. Payment for E&M office/outpatient visits will be simplified, and payment will vary, primarily based on attributes that do not require separate, complex documentation. 

Here are the policies that CMS is currently finalizing to be implemented in January 2021:

• Reduction in the payment variation for E&M office/outpatient visit levels by paying a single rate for E&M office/outpatient visit Levels 2 through 4 for established and new patients while maintaining the payment rate for E&M office/outpatient visit Level 5 in order to better account for the care and needs of complex patients;
• Permitting practitioners to choose to document E&M office/outpatient Level 2 through 5 visits using medical decision-making or time instead of applying the current 1995 or 1997 E&M documentation guidelines, or alternatively practitioners could continue using the current framework;
• 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
• When time is used to document, practitioners will document the medical necessity of the visit and that the billing practitioner personally spent the required amount of time face-to-face with the beneficiary.  

All of these changes allow for a better patient experience and reduce your documentation burden. It is critical that you and your staff keep up with these changes as they ensure that your practice is in step with federal guidelines, oh and did I say Happy New Year?

Send questions and comments to [email protected].

1. Centers for Medicare & Medicaid Services. Final policy, payment and quality provisions changes to the Medicare Physician Fee Schedule for calendar year 2019. www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year. Published November 1, 2018. Accessed December 11, 2018.