News: CMS holds call on E/M documentation guidelines and reporting burdens

Recently, a representative from the Hospital and Ambulatory Policy Group at CMS held a listening session about proposed updates to the documentation guidelines for evaluation and management (E/M) services section of the Current Procedural Terminology (CPT®) code set used by physicians.

During the session, stakeholders were asked to provide their feedback in order to develop policy proposals for upcoming notice and comment rulemaking. CMS asked participants six questions focused on reducing and amending the 1995 and 1997 documentation requirements for E/M.

In response to these questions, callers consistently complained that the documentation requirements are repetitive, especially when it comes to the family and social history categories. According to the callers, the entirety of the E/M system should focus more on medical decision making and less on the patient’s history for assigning levels as well.

Significantly for CDI professionals, many of the callers also requested that the guidelines be revised to reflect the team-based care that’s provided to patients, allowing clinicians to rely on other staff members, including licensed practical nurses, to capture certain elements of the documentation. The current rules related to other providers’ documentation in the EHR, the callers complained, are confusing and burdensome. Last month, CMS announced updates to the use of student documentation for E/M.

Despite the burdens expressed during the call and the limitations in the current E/M code set, CMS stated during the call that their short-term goals focus on revising the guidelines rather than completely restructuring the system.

E/M code assignment has been a target of the Office of the Inspector General and other auditors for some time. In 2014, the agency found that more than $6.5 billion in Medicare payments for E/M were incorrectly coded or documented.

Editor’s note: To listen to the recording of the call or read the transcript, click here. To read about some other takeaways from the call, read this article on the Sheppard Mullin Health Law Blog. Coming soon: Evaluation & Management Coding and Documentation for CDI Professionals by Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP.