There was an OIG report in 2014 that warned about copy/paste and over documentation. The details are below.īased on the changes summarized above and detailed below, it would seem that CMS does not care about the issue of copying and pasting from a prior record. CMS is now allowing clinicians to “review and verify” rather than re-document the history and exam.CMS has made significant changes in E/M notes to reduce burden on practitioners in the past years.“Therefore, we proposed to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team.” In 2020, CMS made a radical change to documentation requirements, adopting this as a policy, In 2019, CMS updated the section of the Medicare Claims Processing Manual that addressed E/M services in teaching settings, allowing a nurse, resident or the attending to document the attending’s presence during an E/M service. They stated that a clinician no longer had to re-document the history and exam, but could perform those and “review and verify” information entered by other team members, or entered in prior notes. In the 2019 Physician Fee Schedule Final Rule, CMS stated its desire to reduce the burden of documentation on practitioners for E/M services, in both teaching and non-teaching environments. In 2018, CMS changed the requirements for using medical student E/M notes by the attending physician. Summary of changes described in this article If you are reviewing records that used those guidelines (office visits before 2021, other E/M before 2023) this is relevant to those services. Only the billing practitioner could document the history of present illness (HPI). The billing physician/NP/PA needed to document that that information had been reviewed and verified. Both the 19 evaluation and management (E/M) documentation guidelines stated that ancillary staff could record a review of systems (ROS), and past medical, family, and social history (PFSH) in a patient record.
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