CMS says it will reduce documentation/coding requirements  

The Centers for Medicare and Medicaid Services (CMS) has announced that it will be taking steps to reduce the administrative burden associated with its documentation and coding requirements in 2019 and 2021.    

CMS says that effective January 1, 2019, it will…

– “Simplify the documentation of history and exam for established patients such that when relevant information is already contained in the medical record, clinicians can focus their documentation on what has changed since the last visit rather than having to re-document information.”

– “Clarify that for both new and established E/M office visits, a chief complaint or other historical information already entered into the record by ancillary staff or by patients themselves may simply be reviewed and verified rather than re-entered.”

– “Eliminate the requirement for documenting the medical necessity of furnishing visits in the patient’s home versus in an office.”

– “Remove potentially duplicative requirements for certain notations in medical records that may have previously been documented by residents or other members of the medical team.”

And in 2021, CMS intends to…

– “Implement a single payment rate for visits currently reported as levels two, three, and four. These represent a majority of office/outpatient visits with clinicians. This means that for the majority of visits, the required documentation related to payment will be limited to what is required for a level two visit.”

– “Retain a separate payment rate for the most complex patients – those currently reported through use of the level five codes. Also, we will retain the current separate code for level one visits, which are predominantly used for visits with clinical support staff.”

– “Introduce coding that adjusts rates upward to account for additional resource costs inherent and routine in furnishing certain types of non-procedural care. These codes would only be reportable with level two through four visits, and their use generally would not impose new per-visit documentation requirements.”

– “Introduce coding that adjusts rates upward for use with level two through four visits to account for the additional resource requirements when practitioners need to spend extended time with a patient.”

– “Allow for flexibility in how level two through five visits are documented – specifically introducing a choice to use the current framework, medical decision-making, or time.”

Click for CMS letter