Mutual Matters

CMS Proposes Potential Changes to Documentation Requirements

Posted by Scott R. Grubman, Esq. on Aug 23, 2018 11:57:40 AM


On July 27, 2018, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule containing numerous proposed changes to the Medicare physician fee schedule and other Medicare policies. The proposed rule is intended to update Medicare’s payment systems to better reflect the relative value of services. 

Among the many potential changes are proposed updates to Medicare’s policies concerning documentation requirements for Evaluation & Management (E/M) services in outpatient or office settings. Currently, providers can choose between two versions of CMS guidance commonly referred to as the 1995 or 1997 E/M Documentation Guidelines. Both versions follow the same general framework to determine the appropriate billing code level based on three documentation components: (1) History of Present Illness (HPI), (2) Physical Exam, and (3) Medical Decision Making (MDM). Each of the three components measures multiple factors that a practitioner can consider when determining the proper E/M level for a visit. 

One major change CMS has proposed is to allow practitioners to choose, as an alternative to the current framework, either MDM or time, as a basis to determine the appropriate level of E/M visit. Under the proposal, a practitioner who chooses an E/M level based on MDM alone would need to document the medical necessity of the visit, plus two of the three MDM factors that measure the number of problems, data reviewed, and risk.  A practitioner who chooses an E/M level based on time alone would need to document the medical necessity of the visit, plus the total amount of time the billing practitioner spent face-to-face with the patient. If this change becomes final, CMS states in the proposed rule that practitioners who wish to continue using the current framework may do so.

Find out more about the changes by clicking below. 

Find out more

Topics: Billing and Reimbursement, Patient Care and Interaction

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