Beginning in January 2019, the Centers for Medicare and Medicaid Services (CMS) changed the rules for who may document information in the patient’s medical record. New rules allow physicians to verify documentation of ancillary staff for various components of the evaluation and management (E/M) service including chief complaint, history of present illness, past medical, family and social history and review of system, rather than re-entering the information. The same holds true for documentation provided by the patient. Many physicians are unaware of this change and may still be following the old and more stringent rules which required the physician to re-document entries made by ancillary staff.
Physicians need only indicate in the patient’s record that they reviewed and verified the information. The physician’s exam and the medical decision-making part of the E/M must still be performed by the physician, however.
One caveat – state law or institutional policies on scope of practice for ancillary staff take precedence over these rules.