Consider This Current CMS CR to Decrease Teaching Physician Documentation Distress

Posted on 14 Jun, 2019 |comments_icon 0|By Bruce Pegg

If you’ve been following the Centers for Medicare and Medicaid Services (CMS) proposals for revamping the evaluation and management (E/M) guidelines, you’ll know that part of the goal for these efforts is to simplify the regulations, especially the documentation, for these services.

Those attempts continue with Change Request (CR) 11171, which was published on April 26, 2019 and which CMS will start to implement on July 29. This time, the focus is on changing the process of documenting E/M services performed by teaching physicians and residents in teaching settings.

Get to Know Teaching Physician Changes

CR 11171 contains some subtle, yet important, changes to the language contained in Chapter 12, Section 100.1 of the Medicare Claims Processing Manual, which deals with the way teaching physicians are paid for services in teaching settings..

Previously, section 100.1.1, which addresses teaching physicians’ participation in E/M services, stated that “Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician.”

Now, with CR 11171, CMS allows “the presence of the teaching physician during E/M services [to] be demonstrated by the notes in the medical records made by physicians, residents, or nurses.”

In addition, the CR emphasizes that “the patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.”

Reap the Patients Over Paperwork Benefits

The changes reflect CMS’s ongoing effort to “‘cut the red tape’ to reduce burdensome regulations,” which began with the 2017 “Patients over Paperwork” initiative. The efforts continued at the end of last year with the 2019 Medicare Physician Fee Schedule (PFS) Final Rule, where CMS outlined four specific ways providers could now reduce E/M paperwork by eliminating unnecessary duplication of information in a patient’s medical record.

Three of those ways included

  • Removing the requirement for providers to re-enter a chief complaint or historical information into the medical record if it has already been entered by a new or established patient or a member of your practice staff
  • Removing the requirement for providers to redocument an established patient’s history and exam if it is already in the medical record
  • Removing the requirement for providers to document medical necessity when visiting a patient at the patient’s home if the patient is unable to visit your office.

CR 11171 removes a fourth requirement by addressing a specific stakeholder complaint in the 2019 Final Rule that “documentation requirements for E/M services furnished by teaching physicians are burdensome and duplicative of notations that may have previously been included in the medical records by residents or other members of the medical team.”

Determine the Impact

With this Change Request, a teaching physician no longer has to rewrite any notes written by medical students in a patient’s medical record. Instead, providing those notes record how the teaching physician has participated in the E/M service, the resident or a nurse can write the note, and the teaching physician can simply sign off on it.

Learn More

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Bruce Pegg
Editor, Newsletters

An experienced teacher and published author, Bruce is TCI’s new voice of primary care, delivering advice and insights every month for coders in the fields of family, internal, and pediatric medicine through Primary Care Coding Alert and Pediatric Coding Alert. Additionally, he is the current editor of E/M Coding Alert. Bruce has a Bachelor of Arts degree from Loughborough University in England and a Master of Arts degree from The College at Brockport, State University of New York. He recently became a Certified Professional Coder (CPC®), credentialed through AAPC.

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