Orthopedic Coding Alert

‘Patients over Paperwork’ takes it up a notch this year.

In 2017, CMS started its “Patients over Paperwork” initiative, which tasked federal agencies with reducing the paperwork burden on healthcare providers — freeing them up to focus more on patient care than (at times) redundant documentation.

According to CMS at the time of the launch, Patients over Paperwork “directs federal agencies to ‘cut the red tape’ to reduce burdensome regulations.” With the release of the 2019 Medicare Physician Fee Schedule (MPFS), it seems the feds are starting to make good on that promise.

Check out these important 2019 aspects of Patients over Paperwork, and learn how they will affect your coding going forward.

Observe These 4 New Documentation Rules

The CMS effort to reduce paperwork kicks off in the 2019 Final Rule with a focus on removing “potentially duplicative requirements for certain notations in medical records that may have previously been documented by residents or other members of the medical team,” according to CMS.

To support the Patients Over Paperwork initiative, CMS finalized the following optional but “broadly supported documentation changes for E/M visits.” Significantly, the Final Rule tries to help you do this in four specific ways:

1. If a medical student working in your practice writes notes in a patient’s medical record, your provider will no longer have to rewrite the note. Instead, your provider can simply sign off on the note, and you can then use it for billing purposes.

Effect: “Implementation of these policies will streamline documentation requirements, reducing paperwork burdens that interfere with a meaningful patient-physician relationship,” observes Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

2. Your provider will now no longer have to re-enter a chief complaint or historical information into the medical record if it has already been entered by a new or established patient or a member of your practice staff. Instead, your provider will simply have to review the information and verify that it is correct.

Effect: “This area is a little confusing,” relays Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “Are they talking about the HPI [history of present illness]?” Holle asks. The way the rule is worded, she wonders if they are referring to HPI, or just past medical (PM), family (F), or social (S) history? Or is it some combination of these history elements?

“I have no problem if clinical staff record the appropriate history, but I feel the providers should show their involvement other than a ‘click’ button that it was reviewed,” Holle cautions. “My fear is something will be missed; remember, staff are not providers — and I am not putting down staff. If the provider doesn’t have to ask any questions when going in the room, something could be missed,” she says.  

3. Similarly, your provider will not have to redocument an established patient’s history and exam if it is already in the medical record. Instead, your provider will simply have to document anything that has changed since the patient’s previous visit.

Effect: Holle has questions about this rule as well, as its explanation of history is incomplete. The rule “states historical information; I am wondering if they mean PM, F, S, versus HPI,” she says.

4. Finally, your provider will no longer have to document medical necessity when visiting a patient at the patient’s home if the patient is unable to visit your office.

Effect: This rule should go a long way toward expanding care for our ever-growing population of elderly patients. “Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors,” reports Falbo.

Experts Cautiously Optimistic

As with all changes in the coding community, most experts are cautiously optimistic, taking a wait-and-see approach until the rules jump from the MPFS and into action in the clinical setting.

This “documentation relief is good news,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Some experts, however, have voiced a note of caution. The new rules “currently seem a little vague, and individual offices may interpret this information in a variety of ways,” notes Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

However, Johnson takes a long-term view of the changes. In the end, “the rules will provide each of us with opportunities to question and fine tune them, eventually leading to more precise guidelines, which will ultimately help the industry,” Johnson believes.