decisionhealth Newsletters, Coder Pink Sheets - 2017 Issue 9 (September)
Understanding E/M: Medical decision-making, time may newly define E/M services
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Article Overview
This article covers proposed changes to evaluation and management (E/M) reporting under a Medicare fee schedule proposal, including CMS’s discussion of revising longstanding documentation guidelines. It is aimed at coders, auditors, clinicians, and practice managers who follow E/M policy updates and documentation requirements. The piece outlines the broad areas under consideration, the role of technology and electronic records, and stakeholder commentary on possible reform directions.
Why This Topic Matters
E/M documentation drives a large volume of physician billing and is central to claim support, compliance, and workflow. Understanding proposed policy shifts helps healthcare organizations prepare for documentation and reporting changes.
Article Sections
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What the future might hold
Introduces the policy context and explains why CMS is reviewing existing E/M documentation guidance. Summarizes the broader reasons the agency is considering reform and the expected impact on daily workflows.
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History and physical exam get the axe
Discusses the possibility of reducing or removing emphasis on long-standing documentation elements in E/M visit reporting. Presents CMS’s call for feedback and stakeholder reaction at a high level.
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Medical decision-making, time move to the fore
Covers the possibility that other documentation factors may become more central in determining E/M visit level. Notes concerns and perspectives from multiple specialties on how future guidance could affect practice patterns.
What You Will Learn
- Why CMS is considering revisions to E/M documentation guidance
- What broad documentation areas are under review in the proposed reform
- How technology and electronic health records factor into the discussion
- Which types of stakeholders are weighing in on the potential changes
- What operational issues practices may need to monitor as policy evolves
Who Should Read This
- Medical coders
- Compliance staff
- Physicians and clinicians
- Practice managers
- Revenue cycle professionals
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