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.
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.”
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
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.”
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.
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