For 2019, CMS has proposed significant changes to the documentation guidelines for the office visit/urgent care codes but has elected not to apply these changes to the more complex ED environment. The new patient and the established patient office visit codes would be collapsed for levels 2–5, with a single payment rate and the ability for the provider to choose the current 1995 documentation guidelines or perhaps score it simply based on MDM or time.

ED Documentation Not Impacted

CMS also proposes leaving ED codes alone:

“We are not proposing any changes to the emergency department E/M code set or to the E/M code sets for settings of care other than office-based and outpatient settings at this time. However, we are seeking public comment on whether we should make any changes to it in future years, whether by way of documentation, coding, and/or payment and, if so, what the changes should be.”

Teaching Physician Documentation

In an effort to reduce the physician documentation burden, CMS proposes eliminating duplicative documentation requirements for teaching physicians (TPs) when the required information has already been documented by someone else. CMS specifically proposes the following:

“The medical records must document the extent of the teaching physician’s participation in the review and direction of services furnished to each beneficiary, and that the extent of the teaching physician’s participation may be demonstrated by the notes in the medical records made by a physician, resident, or nurse.”

If this documentation relief is enacted, TPs would be spared from re-documenting large components of the medical record, and a TP’s involvement could be recorded by another physician, resident, or nurse.

In another win for TPs, Medicare issued a regulatory update related to medical student documentation, clarifying that the TP does not have to re-document items in the medical record entered by medical students, and although the TP must perform the components of the medical service (such as a physical exam and MDM), they do not have to re-document a full note. Just a TP signature is required following the medical student’s documentation:

“If the teaching physician chooses to rely on the medical student documentation and chooses not to re-document the E/M service, contractors shall consider this requirement met if the teaching physician signs and dates the medical student’s entry in the medical record.”

Dr. Granovsky is the president of LogixHealth, an ED coding and billing company, and serves as the course director of ACEP’s coding and reimbursement courses. Email him questions at mgranovsky@logixhealth.com.

Documentation School

For more information on ED documentation issues, check out these classes at ACEP18 in October:

• Rev Up Your Procedural and Critical Care RVUs: Wednesday,
  Oct. 3, 8–8:50 a.m.
• RVU Killers: The Most Common Reimbursement Documentation Errors:
  Thursday, Oct. 4, 8–8:25 a.m.