The 2019 Medicare Documentation, Coding, and Payment Update


This year's changes include some welcome documentation relief, new codes for portal and telephone encounters, and much more.

Fam Pract Manag. 2019 Jan-Feb;26(1):23-28.

Author disclosures: no relevant financial affiliations disclosed.

January always ushers in changes to the Medicare program that affect physician payment and coding, but this year's update is more notable because it includes changes to the documentation requirements, a variety of coding updates, and some added flexibility in Medicare's Quality Payment Program (QPP). Here's a summary of the changes most relevant to family physicians.


In 2019, the Centers for Medicare & Medicaid Services (CMS) offers physicians some documentation relief, especially as it relates to evaluation and management (E/M) coding.

CMS is simplifying the documentation of history and exam for established patients. Before 2019, the E/M documentation guidelines provided some limited flexibility in documenting the history of an established patient. For example, a review of systems (ROS) or a pertinent past, family, or social history (PFSH) obtained during an earlier encounter did not need to be re-recorded if the record contained evidence the physician reviewed and updated the previous information. Similarly, the ROS or PFSH could be recorded by ancillary staff or on a form completed by the patient; to document that the physician reviewed the information, he or she simply needed to add a notation supplementing or confirming the information recorded by others.

CMS is expanding this flexibility in 2019. For both history and exam, physicians are only required to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements. Physicians do not need to re-record these elements (or parts thereof) if the record contains evidence that they reviewed and updated the previous information. Additionally, for both new and established patients, physicians no longer must re-enter information in the medical record regarding the chief complaint and history (including the history of present illness) that either ancillary staff or the patient have already entered.

A physician could choose to re-enter or bring forward information when documenting a visit. However, this is now optional.

CMS is doing something similar for teaching physicians. Federal regulations previously required teaching physicians to personally document their participation in the medical record for E/M visits and to document the extent of their participation in the review and direction of services furnished to each Medicare beneficiary. Medicare has amended those regulations so that, with some exceptions, the notes of a resident or other member of the medical team may suffice instead, and the onus of documentation doesn't always fall on the teaching physician. (See the related Q&A in the “Coding & Documentation” department.)

Lastly, CMS


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Kent Moore is senior strategist for physician payment, for the American Academy of Family Physicians in Leawood, Kansas....

Dr. Mullins is medical director for quality improvement, for the American Academy of Family Physicians in Leawood, Kansas.

Erin Solis is manager of healthcare finance and delivery, for the American Academy of Family Physicians in Leawood, Kansas.

Barbara Hays is former coding and compliance strategist for the American Academy of Family Physicians in Leawood, Kansas.

Author disclosures: no relevant financial affiliations disclosed.


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