CMS clarifies the CC & ROS documentation changes for E/M services for 2019

Dec. 19, 2018 / By Barbara Aubry, RN

Yesterday, I saw a new release from CMS clarifying documentation requirements for E/M services in 2019. Little has changed about the data that needs to be collected, but there has been a change in the provider’s required actions. As I completed reading the CMS update I next saw the results of a study that impacts the changes.

Researchers looked to determine how often primary care providers documented patient complaints of sleep, pain, anxiety, depression and low energy/fatigue (SPADE) during clinic visits. The study: A qualitative study of patients’ perceptions of the utility of patient-reported outcome measures of symptoms in primary care clinics” published in Quality of Life Research, December 2018, Volume 27, Issue 12, pp 3157-3166 by Tasneem et al:

Five themes emerged:

  1.  Patient Reported Outcomes (PROs) may foster communication about symptoms;
  2. Data from PROs may prompt clinical actions;
  3. The visual display of symptom scores could be useful for patients and providers, though modifications may enhance interpretation;
  4. Implementation may vary according to patients’ perception of PRO features (e.g., length);
  5. PROs may be useful, but only to the extent that they are valued, prioritized, and used

However, “According to patients, the use of PROs to measure symptoms in primary care clinics has the potential to be useful. However, patients are reluctant to complete PROs if they perceive that clinicians do not use the measures to improve care. Barriers to implementation in primary care (e.g., duration of visit) should be addressed to enhance the utility of PROs. Clinical trial registration ID: NCT02383862.”

So, if patients feel they either do not want to bother their busy doctor, or that the information they share with their doctor is not important enough to be included in their medical record, what exactly is the point of the E/M changes? And how do patient reported CC or ROS make it in to the EHR since few patients have access to add data to the health systems? In my humble opinion, the logistics of what seems like a good idea has not been entirely thought out. Will scribes be needed to enter the patient generated data? Nurses? Someone else?

Regardless, the clarifications from CMS:

November 26, 2018 Evaluation and Management (E/M) Visit Frequently Asked Questions (FAQs) Physician Fee Schedule (PFS) This document addresses Frequently Asked Questions (FAQs) regarding documentation and payment for evaluation and management (E/M) visits under the Medicare Physician Fee Schedule (PFS).

What parts of the history can be documented by ancillary staff or the beneficiary starting in CY 2019?

  1. The CY 2019 PFS final rule expanded current policy for office/outpatient E/M visits starting January 1, 2019 to provide that any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the beneficiary does not need to be re-documented by the billing practitioner. Instead, when the information is already documented, the billing practitioner can review the information, update or supplement it as necessary, and indicate in the medical record that she or she has done so. This is an optional approach for the billing practitioner, and applies to the chief complaint (CC) and any other part of the history (History of Present Illness (HPI), Past Family Social History (PFSH), or Review of Systems (ROS)) for new and established office/outpatient E/M visits. To clarify terminology, we are using the term “history” broadly in the same way that the 1995 and 1997 E/M documentation guidelines use this term in describing the CC, ROS and PFSH as “components of history that can be listed separately or included in the description of HPI.” This policy does not address (and we believe never has addressed) who can independently take/perform histories or what part(s) of history they can take, but rather addresses who can document information included in a history and what supplemental documentation should be provided by the billing practitioner if someone else has already recorded the information in the medical record.

Perhaps CMS will further clarify who will be responsible for entering patient generated data in the EHR? Stay tuned…

Barbara Aubry is a senior regulatory analyst for 3M Health Information Systems.