The 2019 Medicare Documentation, Coding, and Payment Update

Kent Moore; Amy Mullins, MD, CPE, FAAFP; Erin Solis; Barbara Hays, CPC, CPMA, CPC-I, CEMC


Fam Pract Manag. 2019;26(1):23-28. 

In This Article

Changes in Medicare Documentation Policy

In 2019, the Centers for Medicare & Medicaid Services (CMS) offers physicians some documentation relief, especially as it relates to evaluation and management (E/M) coding.

CMS is simplifying the documentation of history and exam for established patients. Before 2019, the E/M documentation guidelines provided some limited flexibility in documenting the history of an established patient. For example, a review of systems (ROS) or a pertinent past, family, or social history (PFSH) obtained during an earlier encounter did not need to be re-recorded if the record contained evidence the physician reviewed and updated the previous information. Similarly, the ROS or PFSH could be recorded by ancillary staff or on a form completed by the patient; to document that the physician reviewed the information, he or she simply needed to add a notation supplementing or confirming the information recorded by others.

"For both history and exam, physicians are only required to focus their documentation on what has changed since the last visit or on pertinent items that have not changed."

CMS is expanding this flexibility in 2019. For both history and exam, physicians are only 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. Physicians do not need to re-record these elements (or parts thereof) if the record contains evidence that they reviewed and updated the previous information. Additionally, for both new and established patients, physicians no longer must re-enter information in the medical record regarding the chief complaint and history (including the history of present illness) that either ancillary staff or the patient have already entered.

A physician could choose to re-enter or bring forward information when documenting a visit. However, this is now optional.

CMS is doing something similar for teaching physicians. Federal regulations previously required teaching physicians to personally document their participation in the medical record for E/M visits and to document the extent of their participation in the review and direction of services furnished to each Medicare beneficiary. Medicare has amended those regulations so that, with some exceptions, the notes of a resident or other member of the medical team may suffice instead, and the onus of documentation doesn't always fall on the teaching physician. (See the related Q&A in the "Coding & Documentation" department.)

Lastly, CMS has removed the requirement that the medical record must document the medical necessity of furnishing a visit in the home rather than in the office. If the encounter is medically necessary, where it occurs is immaterial.

CMS had proposed some additional, significant E/M documentation changes, such as relaxing the requirements and using a single blended payment rate for codes 99212–99215. However, after hearing many concerns from physician groups, CMS decided to revise and delay those proposals until 2021.