CMS is finalizing a number of documentation, coding, and payment changes to reduce administrative burden and improve payment accuracy for office/outpatient evaluation and management (E/M) visits over several years. For calendar years (CY) 2019 and 2020, CMS is implementing several documentation policies to provide immediate burden reduction, while other changes to documentation, coding, and payment would be implemented in CY 2021.
For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E/M office/outpatient visits, and practitioners should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits billed to Medicare. For CY 2019 and beyond, CMS is working to finalize the following policies:
- 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. They need not re-record the defined list of required elements, if there is evidence that the practitioner reviewed the previous information and updated as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
- Additionally, CMS is clarifying that for E/M office/outpatient visits, for new and established patients, 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;
- Remcmoval 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.
Beginning in CY 2021, CMS will further reduce burden with the implementation of payment, coding, and other documentation changes. Payment for E/M office/outpatient visits will be simplified and payment would vary primarily based on diagnosis that do not require separate, complex documentation.
Specifically for CY 2021, CMS is finalizing the following policies:
- 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.
There will be other changes to note later in the year as CMS moves forward. AMS will continue to keep physician updated on these changes.
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