In my October 2017 article for Rheumatology Practice Management, titled, “Are the 1995 and 1997 Evaluation and Management Documentation Guidelines on Their Way Out?” I discussed the Centers for Medicare & Medicaid Services (CMS) proposal to revise the 1995 and 1997 Evaluation and Management (E&M) Documentation Guidelines. Because changes to E&M documentation and coding may have a dramatic impact on physician documentation, I wanted to provide you with an update.
On March 21, 2018, CMS held a listening session for the provider community and other interested parties. The listening session was structured around attendee responses to questions in 6 areas.
The first question attempted to broadly elicit ways to reduce the burden associated with the documentation of patient E&M visits. The second question was designed to gain input from attendees on approaches that other payers take to both payment and documentation regarding E&M visits. The third question was designed to obtain information on the role of each currently required item in the E&M visits, specifically the medical history, physical examination, and medical decision-making. The fourth question addressed documentation through changes to the underlying E&M code set. The fifth question asked attendees to provide input on the burden of repetitive documentation for visits that are already in the medical records. Finally, the sixth question was designed to obtain information about specialty-specific changes to E&M visits.
It was a fascinating 90-minute phone call that was attended by representatives of large physician groups, national specialty societies, and a few consultants to the industry, such as this author. It truly was a “listening session,” with no contemporaneous comments or feedback from CMS. One of the more interesting aspects of the session was the consensus, regardless of specialty, by the physician attendees. Some examples include:
- There is a need to emphasize the medical decision-making for patients with multiple chronic diseases over the medical history and examination
- There should be less emphasis on medical history elements, especially with electronic medical records automatically carrying some information forward from visit to visit. For example, one commenter lamented that a physician could get down-coded for a complex patient merely because a family medical history was not obtained, calling that “punitive”
- Eliminate the requirement that only the physician can document “History of Present Illness.” Technology will soon be common in physicians’ offices, allowing patients to enter their own history of present illness; requiring the physician to do this adds nothing to the quality of care or toward achieving positive outcomes
- Reduce the number of service levels for office visits from 5 to 3 or 4
The listening session was part of CMS’ ongoing efforts to engage the physician community in the rule-making process. Any changes that CMS would propose to coding or documentation requirements would be addressed in the calendar year 2019 Physician Fee Schedule proposed rule, which is scheduled to be published on or about July 1 of this year. The proposed rule will, as always, be open for public comment.
Rheumatologists have some of the most complex cases to treat of any internal medicine subspecialty. Therefore, it is important that they take a look at the proposed rule and provide their thoughtful comments for the agency’s consideration in the final rule and going forward.