Clinical Documentation

Patients Over Paperwork? Or just part of an agenda to reduce costs?

The Center for Medicare and Medicaid Services (CMS) has started the annual roll-out of proposed changes to the physician and other fee schedules. Wrapped up in the 2019 proposals, and opened for comment from the public and stakeholders, is a proposal regarding evaluation and management codes (E&M). The proposal is shrouded in the idea that it puts patients over paperwork by reducing the clinical visit documentation requirements for physicians, but ignores the reasons why there is a higher standard of documentation associated with the E&M codes that are reimbursed at higher levels because of the time and effort required to treat and evaluate the patient.

Under the proposal, all E&M visits (ie: most outpatient office visits) will be reimbursed at the same dollar amount, regardless of the level assigned to the visit and without needing to meet the current documentation standards for the level; however, providers must still code the level of the visit accurately. Beyond the concerns that we are taking a step backwards as an industry in respect to encouraging quality, detailed patient care documentation that truly tells the patient story, and that lowering documentation standards does little to support value-based care initiatives, physicians treating complex patients are financially penalized under this proposal.