By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD
July 10, 2019
Until this year, if anyone other than the doctor took part of the history, the doctor had to do it again. The Centers for Medicare and Medicaid Services has removed that requirement. Here is what you should know about the removal of this requirement, including how you can optimize this change in rules to streamline your coding process.
The documentation guidelines for the Evaluation and Management (E/M) 1995 and 1997 codes are administratively burdensome. In most practices, the way the patient history is gathered results in a duplication of work. In the typical practice, after patients and staff fill out a pre-examination history questionnaire, then the doctor is required to re-document the chief complaint and the history of present illness.
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A change was made in 2019 to ease the documentation burden for us. For both new and established E/M patient examinations, doctors are no longer required to re-document the chief complaint or any history that our staff or patients have already documented if we (the doctors) determine the information is sufficient. Permitting staff and patients to document all the elements of the history with the doctor simply reviewing and updating any information needed reduces the documentation redundancy.
This change does require that we (the physician) must indicate that we have reviewed and verified the information already documented by placing a note in the patient’s chart. With today’s electronic medical records, that requirement can be fulfilled with a simple checkbox.
Rarely do we have a situation where our workload is made a little easier. Most of the time we are required to do more. In this instance, this new rule reduced our workload.
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