The Centers for Medicare & Medicaid Services (CMS), as part of the CY 2019 Medicare Physician Fee Schedule proposed rule, is proposing a historic shift in the documentation requirements associated with clinician office-based Evaluation and Management (E/M) visits for Medicare. This proposal would help to significantly reduce administrative burdens imposed on the nation’s clinicians, allowing them to spend more time with their patients.

The Office of the National Coordinator for Health Information Technology (ONC) was tasked by Congress in the 21st Century Cures Act to work with CMS to reduce clinician burden associated with health information technology.

CMS and ONC heard from stakeholders, specifically physicians, nurse practitioners, physician assistants and other clinicians who bill Medicare that the E/M documentation requirements create a large amount of administrative burden and are frequently not medically necessary.

These guidelines have unfortunately contributed to longer clinical notes, in part driven by electronic templates designed to capture information required by the E/M guidelines. Known as “note bloat,” these lengthy notes often are difficult to read and the core, essential clinical information is extremely difficult to find.

In the proposed physician fee schedule rule, CMS’ proposals would improve flexibility and reduce documentation requirements associated with office/outpatient E/M billing. These are historic changes and, if finalized, would result in significantly less documentation burden for clinicians treating Medicare beneficiaries.

This historic shift should also lead toward more efficient, effective use of electronic health records in clinicians’ offices, improving the workflows needed to support patient-centered care instead of a focus on meeting billing documentation requirements.

Because these are proposed improvements for office visits paid under the Medicare Physician Fee Schedule, we join CMS in encouraging public feedback during the comment period. We will continue to work closely with CMS to help the clinical community learn about the proposed changes and gather feedback from stakeholders on their recommendations on the proposed policies and their impacts on clinical practice and patient care.

This effort, if finalized, will help shift the nation’s electronic documentation away from overly long, form-driven, hard-to-read documents written primarily to satisfy billing requirements to what it was originally intended for – providing high- quality care to patients.

Learn more about the CMS announcement at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-07-12.html