Medical record documentation is required to accurately record pertinent facts, findings, and observations in regards to a patient’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and the evaluation and management documentation of a service is a key part of the medical record.

Evaluation and management (E/M) services provide the nature and amount of physician work, and documentation varies by type of service, place of service, and the patient's status. Providers must ensure that medical record documentation supports the level of service reported to all payers.

E/M Update

As of January 1, 2019 the Centers for Medicare & Medicaid Services implemented several coding and documentation policies to provide immediate burden reduction to providers, especially as it relates to the evaluation and management codes (E/M).

Key Medicare E/M Changes

For 2019 and 2020, the CMS will continue to use the current coding rules and payment structure for E/M office/outpatient visits, so providers can continue to use either the 1995 or 1997 versions of the E/M guidelines to document new or established patient visits billed to Medicare. Below are the key changes rheumatology practices should take into consideration for documenting Medicare E/M services.

  • For established patient office/outpatient visits, focus documentation of history and exam on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information. Providers will still need to review and update the previous information.
  • Providers do not need to re-record the defined list of elements if there is evidence the information was previously reviewed and updated as needed.
  • For E/M office/outpatient visits for new and established patients, practitioners do not need to re-enter information in the medical record of the patient’s chief complaint and history that was previously entered by ancillary staff or beneficiary.
  • Providers can choose to continue using the 1995 or 1997 E/M guidelines if doing so meets their practice needs.

Review of Systems (ROS) and Past, Family, Social History (PFSH) Guidelines

When describing any new ROS and/or PFSH information or making a note that there was no change in the information, providers should list the date and location of the earlier ROS and/or PFSH in the notes for that date of service. To document the provider reviewed the information, a notation supplementing or confirming the information recorded by others per the CMS’s Evaluation and Management Documentation Guidelines should be included.

Although re-recording certain elements is no longer necessary, providers need to provide evidence the information was reviewed, make any necessary updates, and indicate the work in the patient’s medical record for that date of service.

The key documentation guidelines practitioners need to remember when reviewing and updating the ROS and PFSH include: describe any new ROS and/or PFSH information, or note the information has not changed and note the date and location of the earlier ROS and/or PFSH.

E/M Resources

For step-by-step instructions on documenting and coding the correct level of the E/M services, download the following resources for rheumatology practices.

Rheumatology Coding Manual

E/M Coding Chart

E/M Documentation Example

CMS Evaluation and Management Service Guide

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