Regulation of Medicine


CMS Proposes Potential Changes to Documentation Requirements for E/M Visits

By: Scott Grubman, Esq., Chilivis, Cochran, Larkins & Bever

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.

CMS has also proposed removing redundancies and simplifying E/M documentation requirements. Regarding the Review of Systems (ROS) and pertinent past, family, and/or social history (PFSH) elements of a patient’s history, CMS proposes to require practitioners to focus their documentation only on “what has changed since the last visit or on pertinent items that have not changed, rather than redocumenting a defined list of required elements.” This change would apply only to documenting visits from established patients, and it would prevent practitioners from having “to re-record these elements (or parts thereof) if there is evidence that the practitioner reviewed and updated previous information.”

Another redundancy CMS proposes to eliminate is that “for both new and established patients, practitioners would no longer be required to re-enter information in the medical record regarding the chief complaint and history that are already entered by ancillary staff.” Currently, the billing practitioner must enter these items to be credited as supporting the level of E/M visit selected, even if ancillary staff already entered the same information into the documentation. Instead of requiring the billing practitioner to re-enter the exact same data, this proposed change would permit the practitioner to somehow “simply indicate in the medical record that they reviewed and verified this information.”

These changes and many others are not yet final, and stakeholders have until September 10, 2018, to submit formal comments to CMS regarding the proposed rule. After the comment period closes, CMS will consider the feedback from stakeholders and then may choose to alter or withdraw various proposed changes before finalizing the rule.




Want to learn more?

Interested in how MagMutual can help?

View our products


The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.