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CMS Discusses...

Propose Revision to E/M Documentation Guidelines

AAPC release bullentin that among the many provision detailed within the 2018 Physician Fee Schedule Proposed Rule, released July 13, the Centers for Medicare & Medicaid Services (CMS) acknowledges that the current evaluation and management documentation guidelines create an administrative burden and increase audit risk for providers.

"Stakeholders have long maintained that both the 1995 and 1997 guidelines are administratively burdensome and outdated with respect to the practice of medicine, stating that they are too complex, ambiguous, and that they fail to distinguish meaningful differences among code levels.  In general, we agree that there may be unnecessary burden with these guidelines and that they are potentially outdated, and believe this is especially true for the requirements for the history and the physical exam."

In response, CMS announced its intention to undertake a multi-year effort - with the input of providers and other stakeholders - to revise the current E/M documentation guidelines.  This revision will likely include remove of the history and exam documentation requirements.

CMS is specifically seeking comment on whether it would be appropriate to remove the documentation requirements of the history and physical exam for all E/M visits at all levels.  They believe medical decision-making and time are the more significant factors in distinguishing visit levels, and that the need for extended histories and exams is being replaced by population-based screening and intervention, at leave for some specialties... As long as a history and physical exam are documented and general consistent with the complexity of the MDM, there may no longer be a need to maintain such detailed specifications for what must be performed and documented for the history and physical exam ( for example, which and how many body systems are involved.)

On page 374 of the Proposed Rule, as provided in the hyperlink, above.  More details are sure to follow.


Comments on the CMS proposal to review the E/M documentation guidelines are due no later than September 11, 2017, and can be submitted by one of four methods:

  1. Submit electronic comments on this regulation to  Follow the instructions for "submitting a comment.

  2. Mail written comments to:
    CMS-1676-P 2
    Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
    PO Box 8016
    Baltimore, MD 21244-8013
    **All sufficient time for mailed comments to be received before the close of the comment period.

  3. By express or overnight mail.  You may send written comments to:
    Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1676-P
    Mail Stop C4-26-05
    7500 Security Boulevard
    Baltimore, MD 21244-1850

  4. Deliver (by hand or courier) written comments before the close of the comment period to:Centers for Medicare & Medicaid Services, Department of Health and Human Services Room 445-G, Hubert H. Humphrey Building
    200 Independence Ave, SW
    Washington, DC 20201

When commenting, refer to file code CMS-1676-P.


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