Q: Now that portions of the “Patients Over Paperwork” initiative will go into effect Jan. 1, 2019, will there be specific guidelines to tell us just how reduced some of the history documentation will be?
A: The 2019 final rule is scheduled to be published Nov. 23, so we may get some more specific information then. Here are highlights from The Centers for Medicare & Medicaid Services announcement Nov. 1:
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, 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. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
Additionally, we are clarifying that 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; and
Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians.
The last line is somewhat concerning as it conflicts with Physicians at Teaching Hospital Guidelines (PATH). We really do need more specific clarification that these general comments.
It may be prudent to not change much for the time being. And remember, only Medicare is requiring these changes. Commercial payers still follow either the American Medical Association’s CPT E/M guidelines, federal guidelines, or some blend of these.
Q: One of our outpatient physicians says that to support Medicare’s time-based billing purposes, we need to time stamp their progress notes by including the start time and end time that they see the patients. The rest of us say this is an overinterpretation. We think it’s sufficient to state the time spent on the visit with the percent of face to face “counseling/coordinating” care as long as the history of present illness (HPI) supports that those activities occurred. Which is it?
Everyone is a little right on this one. For overall E/M coding by time purposes, such as when a patient presents to discuss a test result or a potential treatment, a statement like, “Spent most of this 25-minute visit talking to Betty about medical versus surgical options as regards her obesity” is fine. In and out times are not required.
However, Medicare has specified that for “prolonged service” codes 99354 and 99355 (and I would apply this to 99358 as well) the time in and out, or actual times spent in that activity, be documented.
Medicare’s changes to the outpatient E/M codes will affect the way time-based coding is documented starting in 2021.
Bill Dacey, MHA/MBA, CPC is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, billing, documentation, and compliance concerns for physicians. Dacey is a AAPC-certified coding instructor and has been active in physician training for more than 25 years. He can be reached at [email protected]