CMS tests easing E/M requirements

Current changes apply to outpatient visits, but they might be expanded to hospital medicine.


In response to complaints about time-consuming and burdensome regulatory documentation, last year CMS proposed substantially reducing documentation requirements and collapsing outpatient office visit E/M levels 2 to 5 into single new codes with a statistically averaged single fee, one for new and one for established patients.

If the approach were successful, CMS intended to extend it to other sites of service, such as inpatient and emergency services.

Image by Getty Images
Image by Getty Images

The change was proposed in July 2018 and would have taken effect on Jan. 1, 2019, for outpatient office visits. However, during the comment period, the medical community expressed serious concern that the change could penalize clinicians caring for patients with complicated illnesses and could create an adverse incentive to spend less time with complex cases.

As a result, in a final rule published Nov. 23, 2018, CMS made some remarkable changes to its original proposal.

Beginning Jan. 1, 2021, office visit code levels 2 to 4 will not be collapsed into a single code, but they will all be paid the same single fee, one for new and one for established patients. Clinicians will bill for the level of service they believe was provided. Documentation requirements for all three will simply be those for level 2 services, so clinicians will be free to document only clinically pertinent information necessary for each patient.

Level 5 services will continue being paid at a higher fee to account for the greater complexity of these patients and will have the same current documentation requirements.

As of Jan. 1, 2019, CMS will continue using the previous coding and payment structure for office visits (1995 or 1997 guidelines), but the documentation requirements will be substantially eased for the history and physical exam during established office visits at all levels of service.

When information relevant to the history and physical exam is already contained in the medical record, clinicians may focus their documentation on what has changed or on pertinent items that have not changed. They do not need to re-record a defined list of required elements if there is evidence that they reviewed the previous information and updated it as needed. Clinicians should still review prior data, update as necessary, and indicate in the medical record that they have done so.

In addition, it is no longer necessary, in the office setting, to re-enter information on the patient's chief complaint and history that has already been entered by ancillary staff or the patient. Clinicians may simply indicate in the medical record that they reviewed and verified this information.

Currently, these changes apply only to outpatient office visits. It's not clear how CMS might change documentation for inpatient E/M services since there are only three levels of service instead of five.

However, it seems likely that something would eventually be done to at least ease the documentation requirements facing hospitalists. Inpatient E/M codes do not specify new or established patients, but there is currently a distinction between initial and subsequent visits. Potentially, the reduction in documentation burden related to these distinctions in the office setting could be carried over to the inpatient setting.

For example, documentation requirements for initial and subsequent visits might be eased. Hospitalists might also be relieved of the burden of re-entering information on the patient's chief complaint and history that has already been entered by ancillary staff or the patient.

The winds of change are blowing. The American Hospital Association and the American Medical Group Association have announced their support for the final rule changes. The effects of this new approach to documentation and reimbursement will have significant implications for hospitalists in coming years. Keeping an eye on the implementation of the new rule will help hospitalists prepare for any changes in their own documentation requirements.