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Patients Over Paperwork Initiative to Streamline Evaluation and Management Documentation Standards to Reduce Clinician Burden

Monday, August 6, 2018


Patients Over Paperwork, a Centers for Medicare & Medicaid Services (CMS) initiative directed towards putting patients first by reviewing and streamlining regulations in order to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience, is proposing a change to the Evaluation and Management documentation standards as part of the proposed physician fee schedule payment rules for 2019. This proposal impacts any healthcare entity that currently bills Medicare Part B for covered professional services.

CMS is proposing the streamlining of Evaluation and Management (E&M) coding and payment changes, which accounts for 40% of Medicare payments, by reducing the administrative burden and improving the documentation standards for E&M visits which has remained unchanged since 1997.

According to CMS, the intent of this proposal is to:

  • Allow practitioners to choose to document office/outpatient E&M visits using medical decision-making or time instead of the current documentation guidelines if they choose
  • Expand current options by allowing practitioners to use time as the governing factor in selecting visit level and documenting the E&M visit, regardless of whether counseling or care coordination dominates the visit
  • Expand current options for documenting the history and physical by allowing practitioners to focus their documentation on what has changed since the last visit or on pertinent items that have not changed rather than re-documenting information, as long as the practitioner reviews and updates the previous information
  • Allow the practitioner to review and verify certain information in the medical record that is entered by the ancillary staff or the beneficiary rather than re-entering it.

As part of improving payment accuracy and simplifying documentation standards, CMS is proposing a single blended rate for new and established patients for E&M levels 2 through 5 and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services. A minimum documentation standard would be established that supports a level 2 visit, with the focus of documentation to be on medical decision making. Level 1 would still have a separate payment rate.

CMS has estimated that the proposed documentation standards would save a clinician up to 51 hours per year, increasing physician productivity while reducing costs.

The deadline for public comment is September 10, 2018. The implementation of the new rule, barring any changes, is January 1, 2019. Only Medicare Part B services are impacted by this change though you can expect Medicaid, Managed Care, and Commercial insurers to follow suit.


Evaluate the reimbursement impact for your organization of being reimbursed at one rate for professional level services 2 through 5, versus the savings from revised documentation standards that focuses on medical decision making. For more information and evaluation assistance, please contact:

Richard T. (Terry) Lang, FHFMA, CPA