Question:

What changes will CMS consider to office/outpatient evaluation and management (E/M) visits in the future?

Answer:

For 2019 and beyond, CMS is finalizing the following policies:

  • Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit;
  • For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners  may choose to focus their documentation on what has changed  since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
  • For E/M office/outpatient visits, for new and established patients for visits, practitioners need not reenter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information;
  • Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E/M visits furnished by teaching physicians.
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