As part of its “Patients Over Paperwork” initiative and based on input from physicians and others, CMS has made some recent changes to the documentation guidelines.
These changes were made as part of an effort to reduce the documentation burden associated with E&M services so they could actually save you time and make documenting patient histories and exams a little easier.
Prior to the change, the E&M guidelines allowed for a previously obtained “Review of Systems” (ROS) and “Past, Family and Social History” (PFSH) of an established patient to be reviewed and updated without having to re-record the information in your documentation.
As it was written, the rule stated that the review and update could be recorded by:
Describing any new ROS and/or PFSH information or noting that there has been no change in the information; and
Noting the date and location of the earlier ROS and/or PFSH
Per the new guidelines:
For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed
Practitioners need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed
For E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information
Per the final rule, and effective January 1, 2019, CMS states:
When relevant information is already contained in the medical record, practitioners would only be required to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements such as review of a specified number of systems and family/social history.
Practitioners would still review prior data, update as necessary, and indicate in the medical record that they had done so. Practitioners would conduct clinically relevant and medically necessary elements of history and physical exam and conform to the general principles of medical record documentation in the 1995 and 1997 guidelines. However, practitioners would not need to re-record these elements (or parts thereof) if there is evidence that the practitioner reviewed and updated the previous information.
Accordingly, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.
Learn more about the relevant Document Plus software features in this TUTORIAL.
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