As we move closer to 2021 and our new E/M guidelines, now is the perfect time to educate our clinicians on the importance of documenting their encounters to include medical necessity.
In the January 2020 issue of CMS MLN on Evaluation & Management under the General Principles of E/M Documentation, we see this guidance; Clear and concise medical record documentation is critical to providing patients with quality care and is required for you to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received and record pertinent facts, findings, and observations about the patient’s health history. Medical record documentation helps physicians and other health care professionals evaluate and plan the patient’s immediate treatment and monitor the patient’s health care over time.
The key here is “record pertinent facts, findings, and observations” and the big word that we as auditors focus on most is pertinent. So often we see clinicians mark review of systems as “negative”, what is pertinent with a mark of negative? How does this tell us pertinent facts about the patient presentation of help to tell the story about how the patient is feeling?
Moving forward, the nature of the presenting problem will become more pertinent to our coding and we will be seeing far less emphasis on things like counting ROS statements or physical exam elements. CMS will re-release their MLN next year on Evaluation and Management so be sure to make sure you are getting these updates as they become available.
For more information on the evaluation management guide, click here.