The world as we knew it

Both the 1995 and 1997 evaluation and management (E/M) documentation guidelines stated that ancillary staff could record a review of systems (ROS), and past medical, family, and social history (PFSH) in a patient record. The billing physician/NP/PA needed to document that that information had been reviewed and verified. Only the billing practitioner could document the history of present illness (HPI). If you are reviewing records that used those guidelines (office visits before 2021, other E/M before 2023) this is relevant to those services.

Summary of changes described in this article

In 2018, CMS changed the requirements for using medical student E/M notes by the attending physician. In the 2019 Physician Fee Schedule Final Rule, CMS stated its desire to reduce the burden of documentation on practitioners for E/M services, in both teaching and non-teaching environments. They stated that a clinician no longer had to re-document the history and exam, but could perform those and “review and verify” information entered by other team members, or entered in prior notes. In 2019, CMS updated the section of the Medicare Claims Processing Manual that addressed E/M services in teaching settings, allowing a nurse, resident or the attending to document the attending’s presence during an E/M service. In 2020, CMS made a radical change to documentation requirements, adopting this as a policy,

“Therefore, we proposed to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team.” [1]

• CMS has made significant changes in E/M notes to reduce burden on practitioners in the past years.
• CMS is now allowing clinicians to “review and verify” rather than re-document the history and exam. The details are below.

Who cares about copy/paste?

Based on the changes summarized above and detailed below, it would seem that CMS does not care about the issue of copying and pasting from a prior record. There was an OIG report in 2014 that warned about copy/paste and over documentation. It said,

“Copy-Pasting. Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location. When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”[2]

Read the OIG report

CMS responded that it agreed that additional guidance was needed and that it intended to work with its contractors in the development of effective guidance. To my knowledge, that guidance was never released.

• The OIG expressed concern about copy/paste and over-documentation in 2014, but this did not lead to CMS standards about the practice.
• Commercial payers are largely silent, as well.

2019 Easing the burden of documentation

In the 2019 Physician Fee Schedule rule, CMS notes that stakeholders have long maintained that the E/M documentation guidelines where “administratively burdensome and outdated.” They finalized several proposals that would provide “significant and immediate burden reduction” in documenting E/M services. In a section titled, “Removing Redundancy in E/M visit Documentation,” CMS said that practitioners would not need to re-document history and exam that was already in the record.

 

“We proposed to expand this policy to further simplify the documentation of history and exam for established patients such that, for both of these key components, 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.” [3]

That long-winded paragraph says that a practitioner would not need to re-record history and exam for established patients that they had reviewed and verified from a prior note.

This was verified by a letter from CMS head Seema Verma. Ms. Verma’s letter went further. It said that effective 1-1-2019, not only could the clinician review and verify history and exam, but for both new and established E/M services, specifically,

“Clarify that for both new and established E/M services, a Chief Complaint or other historical information already entered into the record by ancillary staff or patients themselves may simply be reviewed and verified rather than re-entered”[4]

• In 2019, CMS said that for a new or established patient, the billing clinician could “review and verify” information entered into the record by ancillary staff or patients, rather than re-document.
• CMS included “history and exam” as components that could be reviewed from prior entries and verified, not re-documented.
• Section from 2019 rule and letter from Ms. Verma attached to this article

2020 Expanded “Review and verify”

Perhaps the most shocking change came in the Physician Fee Schedule Final Rule in 2020. CMS noted that stakeholders were questioning whether “students” described in the Medicare claims processing manual referred only to medical students, or if that also referred to nurse practitioner and physician assistant students. Advanced practice registered nurses (APRNs) and physician assistants (PAs) told CMS that they wanted to use the same rules for precepting their students as physicians used when precepting medical students. CMS agreed with them. But, they went farther.

“Therefore, we proposed to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. We explained that this principle would apply across the spectrum of all Medicare-covered services paid under the PFS. We noted that because the proposal is intended to apply broadly, we proposed to amend regulations for teaching physicians, physicians, PAs, and APRNs to add this new flexibility for medical record documentation requirements for professional services furnished by physicians, PAs and APRNs in all settings.”[5]

Read that section in it’s entirety

• In the 2020, CMS established a general principal to allow the physician/NP/PA to review and verify information entered by physicians, residents, nurses, students or other members of the medical team.
• This principle applies broadly for professional services furnished by a physician/NP/PA.

Codes 99202–99215 in 2021, and other E/M services in 2023

In 2021, the AMA changed the documentation requirements for new and established patient visits 99202—99215. Neither history nor exam are required key components in selecting a level of service. This further reduces the burden of documenting a specific level of history and exam. The 2021 CPT book says this regarding history and exam.

“The care team may collect information and the patient or caregiver may supply information directly (eg, by portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in selection of office or other outpatient services.”[6]

• In 2021, for visits reported with codes 99202—99215, history and exam will not be used to select the level of E/M services. This framework was extended to other E/M services in 2023.

What about teaching physicians

CMS began changing the teaching position rules in 2018, with the stipulation about student documentation. The citation from the CMS manual that changed is below.

B. E/M Service Documentation Provided By Students

“Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing.

Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”[7]

What this says is the teaching physician must still do the work. But, the teaching physician doesn’t have to re-document the work. It saves re-documentation on the part of the attending, in the same fashion as the attending doesn’t need to re-document all of the resident’s work.

Documentation performed by medical students, advance practice nursing students and physician assistant students:

Per CMS:

“Therefore, we propose to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This principle would apply across the spectrum of all Medicare-covered services paid under the PFS.”

• Now, physician assistant and nurse practitioner students are treated the same way as medical students for documentation purposes.
• Any physician or NPP who bills a service can “review and verify” rather than re-document.
• Includes “information included in the medical record by physicians, residents, nurses, students or other members of the medical team.”

The CMS rules got a major update with the April 26, 2019 Transmittal 4823. A transmittal is a communication from CMS to the Medicare Administrative Contractors. It is followed by an update to the CMS Claims Processing Manual and the release of a MedLearns Matter article, explaining the change.

The new rules allow the attending, the resident or the nurse to document the attending’s participation in the care of the patient when performing an E/M service. CMS said they were going to do this in the 2019 Physician Fee Schedule Final Rule, released in November of 2018, but the transmittal wasn’t released until April 26, although there is an effective date of January 1, 2019 and an implementation date of July 1, 2019. The transmittal does not include any of the examples of linking statement that were in the manual for so many years. It is brief—here is the section on E/M.

100.1.1 – Evaluation and Management (E/M) Services
(Rev. 4283, Issued: 04- 26-19, Effective: 01-01-19, 07-29-19)
A. General Documentation Requirements

Evaluation and Management (E/M) Services – For a given encounter, the selection of the appropriate level of E/M service should be determined according to the code definitions in the American Medical Association’s Current Procedural Terminology (CPT®) book and any applicable documentation guidelines.

For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate:

• That the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident; and
• The participation of the teaching physician in the management of the patient.

The presence of the teaching physician during E/M services may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.

These are significant changes for all practices, including those in academic settings. We hope that our MACs are paying attention to CMS’s intentions and that other payers follow suit.

References

[1] CMS 2020 Physician Fee Schedule Final Rule

[2] CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs, January 2014 OEI-01-11-00571.

[3] CMS 2019 Physician Fee Schedule Final Rule, page 572

[4] CMS letter from S. Verma, 2019

[5] 2020 Physician Fee Schedule Final Rule, p. 380

[6] AMA, CPT E/M codes, 2021

[7] Medicare Claims Processing Manual, 100-04, Chapter 12, Section 100

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