Documentation requirements for evaluation and management (E&M) services are a subject that provokes the ire of almost all physicians regardless of specialty. The documentation guidelines are outdated, confusing and cause “over-documenting” at the expense of time spent with the patient. CMS agrees and is working to address the issue.
Recently the Advocacy Council participated in a conference call with CMS. They asked for input from the medical community in several specific areas. Although there was no clear consensus, a few themes emerged during the call:
- Medical decision making is the most important factor in determining the level of the visit.
- History and physical should be problem-focused, and the note should not repeat information from previous visits.
- There should be fewer “check the box” requirements.
- CMS should clarify that non-physician clinical staff may document information in the EHR.
Stakeholders on the call were divided, however, on the importance of the history, physical and time in determining the level of thevisit. We had previously commented to CMS that in the allergy specialty, the need for a comprehensive history is critical in reaching a diagnosis and should not be underemphasized in determining the level of visit.
Another point of disagreement was whether the number of visit codes should be increased or decreased. While everyone agreed simplification was the goal, opinions varied on how to accomplish this. Some suggested there should be only three levels while others noted the need to address problem-focused care for multiple chronic conditions – even if those conditions were stable – which might require additional visit codes.
We expect CMS will issue a proposal or request for information sometime this year. We will provide you with updates on this process as it evolves.