Lesley Yeung, Senior Counsel in the Health Care & Life Sciences practice, in the firm’s Washington, DC, office, authored an article in the Journal of Health Care Compliance, titled “Big Changes on the Horizon: Documenting Office and Outpatient E&M Visits.”

Following is an excerpt (see below to download the full version in PDF format):

In October 2017, the Centers for Medicare & Medicaid Services (CMS) launched the “Patients over Paperwork” initiative, meant to reduce unnecessary administra­tive burden, increase efficiencies, and improve the ben­eficiary’s experience when seeking health care services. The goal of CMS’s efforts to identify and eliminate overly burdensome administrative tasks is to minimize distrac­tions and allow practitioners to focus their time and attention on actual patient care.

As part of these efforts to reduce provider burden, CMS made an ambitious proposal this summer to reform evaluation and management (E&M) coding and documentation requirements under the Medicare Part B Physician Fee Schedule (PFS). This proposal, accord­ing to CMS, stems from concerns voiced by health care practitioners that the existing E&M coding guidelines are outdated, complex, ambiguous, and fail to distin­guish meaningful differences among the five levels of E&M office visit codes. CMS’s proposal aims to make use of electronic health records more efficient and effective and to improve documentation workflows to support patient-centered care instead of being focused on meeting billing documentation requirements.

Specifically, CMS proposed to eliminate the existing documentation requirements that differ for each of the five levels of E&M codes for office and outpatient visits. Instead, CMS proposed to adopt a minimum documenta­tion standard, whereby practitioners would have a choice to code based on medical decision making (MDM) or time, or to continue using the current framework based on either the 1995 or 1997 E&M documentation guide­lines. In conjunction with the documentation reform proposal, CMS also proposed to apply single-blended payment rates for new and established patients for office and outpatient E&M visit levels two through five.


Jump to Page

Privacy Preference Center

When you visit any website, it may store or retrieve information on your browser, mostly in the form of cookies. This information might be about you, your preferences or your device and is mostly used to make the site work as you expect it to. The information does not usually directly identify you, but it can give you a more personalized web experience. Because we respect your right to privacy, you can choose not to allow some types of cookies. Click on the different category headings to find out more and change our default settings. However, blocking some types of cookies may impact your experience of the site and the services we are able to offer.

Strictly Necessary Cookies

These cookies are necessary for the website to function and cannot be switched off in our systems. They are usually only set in response to actions made by you which amount to a request for services, such as setting your privacy preferences, logging in or filling in forms. You can set your browser to block or alert you about these cookies, but some parts of the site will not then work. These cookies do not store any personally identifiable information.

Performance Cookies

These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. They help us to know which pages are the most and least popular and see how visitors move around the site. All information these cookies collect is aggregated and therefore anonymous. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance.