‘Cut the Red Tape’, which refers to eliminating unnecessary, outdated, and duplicative burdensome regulations – this is what CMS aims with its “Patients over Paperwork” (PoP) initiative. This initiative launched by CMS Administrator Seema Verma in 2017 also specifically targets burdensome and outdated guidelines imposed on various coding and documentation requirements. Medical billing companies dealing with physicians’ documentation tasks should also be aware of what CMS has proposed to improve coding and documentation.

Through PoP, this agency established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, increase efficiencies and improve the beneficiary experience. CMS is also committed to removing regulatory obstacles that prevent providers from spending time with patients.

Many reports highlight that clinicians spend more time on EHR documentation and other desk work than with patients. CMS is putting this initiative to work by –

  • Reducing burden through coding and documentation reform
  • Talking about E&M code reforms
  • Reforming E&M codes
  • Simplifying office visit documentation
  • Sharing 2019 Medicare Physician Fee Schedule (PFS) final & proposed rule presentations
  • Complexity & burden of hospital reporting
  • Beneficiary care activities & transitions
  • Challenges for beneficiary care transitions
  • Mapping the nursing home experience
  • Implementing MACRA to lessen your burden & costs
  • Reducing documentation requirements
  • Making the medical review process clearer, and
  • Making meaningful measures

Reduced paperwork can help physicians focus more on patient care. According to CMS, the changes introduced by this initiative will result in physicians saving over 51 hours of documentation time per year.

The agency is leveraging Human Centered Design (HCD) to involve customer’s perspective in learning more about provider burden. Based on CMS’ meeting with over 200 hospital leadership, management, and clinical staff; subject matter experts; and hospital associations on reporting information to external and regulatory bodies, it was observed that hospitals want to partner with CMS to improve healthcare and staff at hospital feels they spend too much time resolving misaligned requirements and understanding inconsistent guidance. At the same time, broad policies do not always fit, as each hospital serves a unique population. Based on such observations, CMS is now easing their documentation requirements and giving flexibility, along with maintaining important patient and program integrity protections.

How PoP Impacts Evaluation and Management (E/M) Coding

Recognizing that a major source of burnout is the documentation burden associated with evaluation and management (E/M) coding, CMS has recommended certain regulations and standards. Based on CMS’ updated 2019 Medicare Physician Fee Schedule (MPFS) final rule for E/M documentation requirements, effective January 2019, clinicians and medical coders –

  • Do not have to re-document information that is already contained in the medical record and can focus on documenting only what has changed since the last visit
  • Can review and verify any historical information already entered by ancillary staff or by patients for both new and established E/M office visits, rather than re-entering
  • Can avoid documenting the medical necessity of furnishing visits in the patient’s home versus in an office
  • Can remove any duplicative requirements for certain notations in medical records that may have previously been documented by residents or other members of the medical team

CMS has also proposed certain changes for 2021, such as minimum documentation standards would be put in place for level 2, formerly levels 2-4 and new add-on codes would allow clinicians to report the additional resource costs associated with patients who require significantly more of their time. However, these changes faced opposition and have not been finalized. Reduced documentation tasks can lead to increased productivity. Companies providing medical coding services for E/M documentation should make sure that their coders are up to date with the current and upcoming changes to coding regulations.