Radiology Coding Alert

See what changes will help streamline your documentation processes.

The Medicare Physician Fee Schedule (MPFS) Final Rule for 2019 offers some valuable insights into Medicare’s plans for the immediate and long-term future. Included in this Final Rule, CMS covers a wide variety of topics.

For those interventional radiologists who perform pre- and postsurgical evaluation and management (E/M) visits, CMS introduces the Patients Over Paperwork initiative which, by further streamlining the documentation process, eases a burden on both patient and clinician.

Keep reading for an overview of some of the most important documentation-specific features of the 2019 MPFS Final Rule.

(We’ll cover the general framework of CMS’ final rule proposals in this article, but it’s up to you to dig deeper into the nuances of each vital component. You can access the complete 2019 MPFS Final Rule here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.)

Understand Context Behind Decision for Policy Changes

As one might expect, CMS has not made the decision to incorporate such a drastic set of policy changes out of the blue. Rather, it’s carefully listened to stakeholders’ concerns that “the E/M guidelines, and the code set itself are clinically outdated and may not reflect the most clinically meaningful or appropriate differences in patient complexity and care.” Furthermore, stakeholders argue that some of the documentation requirements are not only redundant, but also “may not account for changes in care delivery, such as a growing emphasis on team-based care, increases in the number of recognized chronic conditions, or increased emphasis on access to behavioral health care.”

This Final Rule addresses these concerns, and more, by not only updating policies to the documentation process, but including 2021 E/M code set and 2019 Merit-based Incentive Payment System (MIPS) guidelines.

Incorporate New Documentation Streamlining Processes

The first policy CMS introduces in the Final Rule comes by way of the Patients Over Paperwork initiative. CMS seeks to address physician concerns of “excessive regulatory requirements and unnecessary paperwork that steal time from patient care” by revising the way that clinicians should report various aspects of the documentation process.

First, it’s important to note that none of these 2019 documentation policies involve changes in the coding or payment process. Instead, CMS is striving to reduce any unnecessary steps within the documentation process that may get in the way of patient care. Specifically, CMS is featuring the following four changes to documentation policy, effective January 1, 2019:

• “Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit;
• “For history and exam 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;
• “Additionally, we are clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter 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;
• “Any staff may enter the chief complaint and history of present illness (HPI). This information does not have to be re-entered by the provider.”

Using these points, the Patients Over Paperwork initiative takes a firm stance on prioritizing efficiency and practicality over repetition. This initiative seeks to do away with some of the more antiquated tasks that are well-known around physician practices for slowing down the productivity rate.

As you can see, while these changes might seem relatively benign on the surface, they can result in a much more efficient documentation process in the long term. “As a coder and as a patient, I can only see the positive in this,” says Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center in Rochester, New York. “I think one of the toughest parts about being a provider is, at times, the documentation that is required can be so repetitive.  While documentation is a necessary part of the visit, the focus should always be on the patient. I feel enabling providers to document pertinent findings and only what has changed just since the last visit promotes good patient care,” Quinlan remarks.