Being able to focus more on patient care than paperwork has long been the desiderata of the physicians. With new CMS regulations for reduced documentation requirements from physicians for their outpatient Evaluation and Management (E/M) office visits, this need seems to be getting addressed gradually, starting from January 1st 2019 to over the next two to three years.
For CYs 2019, and 2020:
- Physicians can continue using either 1995 or 1997 guidelines for documenting E/M office visits for Medicare patients.
- Coders can continue using current coding methodology.
- CMS will continue to pay as per current payment structure.
Effective January 1st, 2019:
- Documentation of medical necessity justification will not be required for a home visit in lieu of an outpatient office visit.
- Re-documentation of the required elements will not be required in case of established patient evaluation and management outpatient office visit when relevant information is already documented in the medical record and the physician has reviewed and updated the prior information as necessary and noted it as such in the medical record for the current visit. Physician can document only the changes or what has not changed since the last visit.
- There will be no need to re-record in the medical record the information about patient’s Chief Complaint and History if that has already been entered by ancillary staff or by the patient, for both new and established outpatient E/M office visits. It will be sufficient for the physician to document in the medical record that such information was reviewed and verified by him/her.
- For E/M visits furnished by teaching physicians, potentially duplicative requirements have been removed for notations that may have previously been included in the medical records by residents or other members of the medical team.
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Starting January 1st 2021:
- There will be a single payment rate for outpatient E/M office visit levels 2 through 4 for both new and established patients.
- The payment rate for outpatient E/M office visit level 5 will be maintained to distinguish the visits of complex patients from other patients’ visits.
- Physicians will be allowed to either document outpatient E/M office visit levels 2 through 5 using Medical Decision Making or Time or continue using the current 1995 or 1997 E/M documentation guidelines.
- For outpatient E/M office visit levels 2 through 4:
- When using MDM or current 1995 or 1997 Evaluation and Management documentation guidelines to document the visit, there will be a minimum supporting documentation standard required to support a level 2 outpatient E/M office visit code for history, exam, and/or medical decision making.
- When using Time to document the visit, physicians will need to document the medical necessity of the visit and the amount of time personally spent face-to-face with the patient.
- Separate add-on codes will be introduced to be only used with outpatient E/M office visit levels 2 through 4 to account for the additional resources inherent in visits for primary care and some kinds of non-procedural specialized medical care that would not be restricted by physician specialty. The use of such add-on codes will not require any new per-visit documentation.
- A new “extended visit” add-on code will be introduced to be used only with outpatient E/M office visit levels 2 through 4 codes to indicate the additional resources required when physicians need to spend extended time with the patient.
Consequently, Payment Amounts for Evaluation and Management Outpatient Office Visits will look like as follows in 2021 (the table as sourced from CMS shows payment amounts based on 2019 payment rates; actual amounts in 2021, when the policy takes effect, will differ—terms referenced for new codes as defined by CMS follow this table):
New Primary Care Complexity Code: Visit complexity inherent to evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services (Add-on code, list separately in addition to level 2 through 4 office/outpatient evaluation and management visit, new or established).
New Non-procedural Specialty Care Complexity Code: Visit complexity inherent to evaluation and management associated with non-procedural specialty care including endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, interventional pain management, cardiology, nephrology, infectious disease, psychiatry, and pulmonology. (Add-on code, list separately in addition to level 2 through 4 office/outpatient evaluation and management visit, new or established).
New Extended Visit Code: Extended time for evaluation and management service(s) in the office or other outpatient setting, when the visit requires direct patient contact of 34-69 total face-to-face minutes overall for an existing patient or 38-89 minutes for a new patient (List separately in addition to code for level 2 through 4 office or other outpatient Evaluation and Management service).
Existing Prolonged Services Code: Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service).
It is being estimated that these new regulations will promote improved room with the physicians to focus better on what is more important and clinically appropriate for their patients rather than having to apply their clinical judgment more towards the documentation requirements.