New Documentation Guidelines for Examinations

Marty Kotlar, DC, CPCO, CBCS

Question:  I heard there are new documentation guidelines for examinations. How is this going to affect my documentation, coding and patient flow?

Answer: As part of its “Patients Over Paperwork” initiative, CMS sought input from providers and other healthcare organizations on how to reduce the documentation burden associated with Evaluation & Management (E/M) services. As a result, CMS introduced new and “relaxed” guidelines effective January 1, 2019. These changes will have a significant effect on patient workflow.

Change #1: When documenting services for new and established E/M visits, the treating provider does not need to “re-document” any part of the chief complaint (CC) or history in the record when recorded by the patient, patient’s family members or ancillary staff. This applies to the CC and any part of the history, including the HPI, ROS, and PFSH. The previous guideline was clear that the CC and HPI statement must be collected and recorded by the provider reporting the service for reimbursement. This required duplicating work and documentation. Under the old guideline, if a provider documented the CC or HPI, it had to be re-documented for reimbursement.

The new guideline allows the entire documentation history to be done by the patient or patient’s family member or staff member. The provider must review the information and update or supplement, as necessary. The documentation also must clearly note that the review was performed.

Change #2: When reporting services for established E/M visits, providers may focus on what has changed or remained unchanged since the last visit. There is no need to re-record elements of the history or exam for established patients. The provider must document the review and update the information already presented in the record.

Previous guidelines had no provision for using documentation from a prior visit except for information related to the review of systems and past, family, and social history. The current CMS guideline for established patient visits indicates that the CC, HPI, and physical exam are now included in the information that can be reviewed and used from a prior visit, provided the review and any edits or supplemental information are documented in the record.

For example, a patient is seen on an initial visit with complaints of low back pain and a diagnosis is made. This visit may require a detailed history and detailed exam in order to make a clinical decision to rule out systemic diseases. On the initial visit, the diagnosis of disc degeneration and subluxation is made, a treatment plan is outlined and reviewed with the patient. This plan may include activity modifications, a HEP, and weight loss. The goal of the follow-up visit is to evaluate the current treatment plan. On the follow-up visit, clinical necessity would dictate a more focused history, concentrating on the HPI and elements of the physical examination of the low back that changed since the initial visit.

Using the new guideline, the provider could document that “the examination of the low back was unchanged from the last visit.” It would not be necessary to repeat the entire physical examination required to make the initial diagnosis. Documentation elements from the physical exam that were necessary and repeated during the follow-up visit should be the focus of the documentation, and those elements or bullets would be counted toward the level of service for the follow-up visit. The provider would not use the detailed history and detailed exam completed at the initial visit to choose the correct level of established patient visit.

Lifting the burden to re-document previously completed work should improve office workflow and office visit scheduling. Be sure to adequately document the review process and edit or update as necessary.

Dr. Marty Kotlar is the President of Target Coding. Over the last 12 years, he has helped hundreds of chiropractors, acupuncturists, physical therapists and massage therapists with compliance as it relates to billing, coding, documentation, Medicare & HIPAA. Dr. Kotlar is certified in compliance, a certified coding specialist, a contributing author to many coding and compliance journals and a guest speaker at many state association conventions. He can be reached at 1-800-270-7044, website – www.TargetCoding.com, email – drkotlar@targetcoding.com.