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).
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,
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