1 minute reading time (200 words)

CMS Seeks Comments on Changes to E/M Documentation Guidelines

Source: Emily Hill, PA, AAPM Coding Consultant
Date: April 4, 2018


In the November 2017 Final Rule, CMS sought comments on potential updates to the Evaluation and Management (E/M) Documentation Guidelines. CMS indicated it was particularly interested in suggestions for initial changes to the history and exam components. CMS further suggested that medical decision making (MDM) and time are more important factors in distinguishing levels of service.

On March 21, 2018, CMS held a public listening session titled E/M Services: Documentation Guidelines and Burden Reduction Listening Session. The purpose of the session was to receive feedback from users regarding the current guidelines and suggestions for potential revisions. More specifically, the session asked questions regarding:

  • Ways to reduce the burden associated with the documentation of patient E&M visits.
  • Ways for CMS to seek input on approaches that other payers take to both the payment and the documentation regarding E&M visits.
  • The role of each currently required item in the E&M visits, specifically the history, physical exam, and medical decision making.
  • Documentation through changes to the underlying E&M code set.
  • Information on duplicative data entry in the medical record.
  • Information about changes to the E&M visits that are specialty specific.
Click here to access links to the audio recording, presentation and transcript.

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