decisionhealth Newsletters, Coder Pink Sheets - 2019 Issue 2 (February)
Changes to E/M guidelines include history and exam; expectations remain murky
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Article Overview
This article covers CMS’s revised 2019 evaluation and management (E/M) documentation guidance and how it affects the division of documentation tasks between physicians and ancillary staff. It is intended for medical practices, coders, and compliance teams that need to understand the scope of the changes, the types of documentation involved, and the broader operational and compliance implications. The discussion stays at a high level and references CMS guidance, practice management concerns, and compliance perspectives without providing a substitute for the premium article.
Why This Topic Matters
E/M documentation changes can affect workflow, audit readiness, and compliance processes across a practice. Understanding which documentation elements may be handled by ancillary staff helps organizations evaluate training, EHR processes, and documentation policies.
Article Sections
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Q&A: New E/M reporting rules
An overview of the question being asked about the revised E/M documentation approach and who can document certain parts of the visit record.
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CMS revised guidelines for 2019
A discussion of the overall focus of the revised guidance and the documentation elements affected by the update.
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Established and new patient documentation
A comparison of how the revised approach applies to different patient categories and the general responsibilities of staff versus providers.
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Example and CMS FAQ reference
A brief illustrative scenario and a reference to CMS’s FAQ material that clarifies the documented history components.
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Practice impact and compliance considerations
Broader commentary on workflow implications, EHR challenges, payer issues, and compliance oversight concerns discussed by practice management and audit-focused sources.
What You Will Learn
- How CMS’s revised E/M documentation guidance changed the documentation workflow
- Which broad documentation elements are discussed in the update
- How the guidance may affect practice operations and compliance processes
- Why some practices see the change as limited in its practical impact
Who Should Read This
- Physicians
- Medical assistants
- Coders
- Compliance staff
- Practice managers
- Revenue cycle professionals
Codes Discussed
Code Ranges Discussed
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