How CMS Final Rule Will Impact E/M Coding and Documentation Requirements

Prior to 2021, providers had to meet certain criteria and address three key areas in the patient’s progress notes: patient history, physical exam, and medical decision making (the thought process used to develop a diagnosis and treatment plan). All categories were required to meet certain thresholds for new patient billing, while only two of the three were needed when billing for established patients.

The documentation changes may take some getting used to, but they will help eliminate providers, including extraneous information just to support a given level of service.

Educating providers on the documentation changes should be a priority, as they are graded quite differently than in the past. It is critical to make sure they adjust their documentation to support the levels they are billing, so they will not face a monetary penalty should an audit occur.