Published 4/1/2019
Margaret M. Maley, BSN, MS

Medicare’s New Documentation Rules Impact Practices

In the November 2018 Federal Register, the Centers for Medicare & Medicaid Services (CMS) released new, relaxed documentation guidelines, effective Jan. 1, which have a significant effect on office workflow.

Changes to new and established outpatient visits

When documenting services for new and established outpatient visits, the billing provider does not need to redocument any part of the chief complaint (CC) or history in the medical record when recorded by the patient, patient’s family members, or ancillary staff. This applies to the CC and any part of the history, including:

  • history of present illness (HPI)
  • review of systems
  • past, family, and social history

What’s different? The previous guideline was clear that the CC and HPI statement must be collected and recorded by the provider reporting the service for reimbursement. This required duplicating work and documentation. Under the old guideline, if a nurse or advanced practice provider documented the CC or HPI, it had to be redocumented by the physician reporting the service under his or her provider number for reimbursement.

The new guideline allows the entire documentation history to be done by the patient, patient’s family member, nurse, physician assistant (PA), or nurse practitioner (NP). The billing provider must review the information and update or supplement, as necessary. The documentation also must clearly note that the review was performed.

Changes to established outpatient visits

When reporting services for established outpatient visits, practitioners may focus on what has changed or remained unchanged since the last visit. There is no need to rerecord elements of the history or exam for established patients. The practitioner must document the review and update the information already presented in the medical record, however.

What’s different? Previous guidelines had no provision for using documentation from a prior visit except for information related to the review of systems and past, family, and social history. The current CMS guideline for established patient visits indicates that the CC, HPI, and physical exam are now included in the information that can be reviewed and used from a prior visit, provided the review and any edits or supplemental information are documented in the medical record.

Using this guideline can be tricky, and we must revisit medical necessity to understand how established patient visits may be audited.

Acknowledging that Medicare considers medical necessity the overarching criterion for the level of service reported, only the elements of the history and exam related to the patient’s problem or condition would be relevant in review. Expanded elements that may have been required to make a diagnosis and medically necessary on the initial visit would not be medically necessary at the time of follow-up.

For example, a patient is seen on an initial visit with complaints of right knee pain. On this visit, the provider is making a diagnosis. The visit may require a comprehensive history and detailed exam in order to rule out systemic diseases like rheumatoid arthritis. On the initial visit, if the diagnosis of osteoarthritis is made, a treatment plan is outlined and reviewed with the patient. This plan may include nonsteroidal anti-inflammatory medications, activity modifications, and weight loss. The goal of the follow-up visit is to evaluate the current treatment plan. On the follow-up visit, medical necessity would dictate a more focused history, concentrating on the HPI and elements of the physical examination of the knee that changed since the initial visit.

Using the new CMS guideline, the physician focusing on the examination of the knee could document that “the examination of the right knee was unchanged from the last visit.” It would not be medically necessary to repeat the entire physical examination required to make the initial diagnosis. Documentation elements from the physical exam that were medically necessary and repeated during the follow-up visit should be the focus of the documentation, and those elements (or “bullets”) would be counted toward the level of service for the follow-up visit. The provider would not use the comprehensive history and detailed exam completed at the initial visit to choose the correct level of established patient visit.

For providers who say, “I repeat the entire examination?”—this is done at his or her discretion, but from an auditing perspective, medical necessity would be challenged because the diagnosis was made on the initial visit, and the patient has no new complaints. The provider should use or take credit only for the bullet points related to the right knee and not the more detailed physical examination that included other body areas evaluated on the initial visit in order to make a diagnosis when determining the level of evaluation and management (E/M) service using the new CMS guideline. There is no medical necessity for the additional exam elements unless the patient’s history has changed.

In its 2019 update to providers, the National Government Services (NGS), the Medicare administrative Part B carrier for 11 states in the east and Midwest, states: “There is a clear expectation that complaint and history information, particularly HPI, be carefully reviewed and noted by the performing provider. In many circumstances, clinical skill is needed to determine the scope and course of questioning relative to this process; the provider remains obligated to assess previously recorded information and to expand upon it as medically necessary.”

It is clear from this guidance that NGS still considers HPI to be the element of history that drives the rest of the service and will continue to focus on HPI in documentation reviews. Not all Medicare carriers have updated their websites with specific information.

It is unclear how commercial payers will respond to the relaxed guidelines. The Current Procedural Terminology book does not address the use of previously documented information or the documentation of the CC and HPI by other members of the healthcare team. Private payers following more restrictive guidelines were adhering to those previously developed by CMS. Practices should confirm that carriers are continuing to follow CMS’ lead with the updated guidelines.

In summary, here are seven important things to remember about the relaxed E/M guidelines from CMS:

  1. Provided that the billing provider documented his or her review, supplementation, or editing of the information, the CC and entire history for a new or established outpatient may be completed by the patient, the patient’s family, ancillary staff, nurses, PAs, or NPs.
  2. The elements documented by others should be used only to choose the “level” of E/M service if they are medically necessary to make a diagnosis or treat the problem.
  3. For established outpatient visits, it is not necessary to redocument history or exam elements in the medical record from a previous visit, provided there is documentation that the billing provider reviewed the history and repeated elements of the exam in order to make a statement about what has changed or remained the same since the previous visit.
  4. Only the elements of documentation relevant to the current visit should be used to choose the “level” of E/M service. Other elements present in the recording of the previous visit that are not necessary for the current evaluation should not be considered in determining the level of E/M service. They are not considered to be medically necessary.
  5. The relaxed guidelines apply to outpatient E/M services only (except where teaching physician guidelines apply).
  6. Lifting the burden to redocument previously completed work should improve office workflow and may alter office visit scheduling.
  7. Be sure the billing provider adequately documents his or her review of the previous documentation and edits or updates it as necessary.

Margaret M. Maley, BSN, MS, is a senior consultant specializing in orthopaedic coding and reimbursement with KarenZupko & Associates.