decisionhealth Newsletters, Coder Pink Sheets - 2017 Issue 12 (December)
Future of E/M documentation: Substantial changes to guidelines, not codes, remains focus for CMS
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Article Overview
This article explains CMS’s planned direction for E/M documentation policy, including possible updates to history and exam documentation and a greater role for medical decision-making. It is relevant to coders, billers, compliance staff, and clinicians who follow Medicare E/M reporting policy and documentation requirements. The piece also summarizes stakeholder reactions and the expected pace of change under the Medicare physician fee schedule.
Why This Topic Matters
E/M documentation policy affects how office and other evaluation and management services are recorded, supported, and audited. Understanding CMS’s direction helps practices monitor compliance requirements and prepare for future documentation updates.
Article Sections
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CMS direction on E/M documentation
Overview of the agency’s stated interest in revising documentation expectations for E/M services and the timing of those changes.
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History, exam, and medical decision-making
Discussion of how history and physical exam documentation are being reconsidered and how medical decision-making is being framed in the policy discussion.
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Stakeholder comments and implementation pace
Summary of reactions from commenters and the expected slow timeline for any guideline revisions.
What You Will Learn
- How CMS is approaching future updates to E/M documentation guidance
- Which documentation elements are being discussed in the policy review
- Why stakeholders view the proposed changes as significant for practices and systems
- What factors may affect the timing and scope of implementation
Who Should Read This
- Medical coders
- Medical billers
- Compliance professionals
- Physicians and other clinicians
- Practice managers
- Revenue cycle staff
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