Get the Latest on Changes to Medicare’s 2019 History Documentation Requirements

We’ve been talking a lot about the 2019 Medicare Physician Fee Schedule final rule, but when there are changes to E/M rules, there can never be enough information, right? CMS recently released a response to a question that arose during a provider call about what parts of history ancillary staff or the beneficiary can document in 2019. Here’s what you need to know.

Go Point by Point Through Medicare’s Answer to the Hx Question

Below are the bullet points to help break down the CMS response into manageable chunks:

  • The 2019 policy applies to office/outpatient E/M visits.
  • For DOS Jan. 1, 2019, and later, the billing practitioner DOES NOT need to redocument any part of the chief complaint or history recorded in the medical record by the ancillary staff or the beneficiary. So this applies to:
    • Chief complaint (CC)
    • History of present illness (HPI)
    • Past family social history (PFSH)
    • Review of systems (ROS).
  • Medicare explains that it’s using “history” as the 1995 and 1997 E/M documentation guidelines use the term, with CC, ROS, and PFSH as “components of history that can be listed separately or included in the description of HPI.””
  • If the billing practitioner does not redocument, then that practitioner DOES need to review the information and update or supplement it as needed. The billing practitioner needs to indicate in the record that he completed this step.
  • This change in approach to documenting the history is optional. The billing provider may of course continue to redocument the information.
    • Bonus tip: Experts advise taking your time implementing the changes. Investigate whether the changes line up with requirements for other payers and regulating bodies before starting big shifts in current practices for documentation. Also note that during the provider call that generated our question in focus, an attendee asked about MACS that have different documentation guidelines for history. The CMS response during the call was that the expectation was that MACs would update their documentation guidelines to be in line with the new national rule.
  • The policy does not specify who may take or perform histories or what parts of the history they can take, Medicare states in the response. The policy is instead about documenting information and supplemental information the billing practitioner muse provide when others put the information into the patient’s medical record.

What About You?

Does the CMS response about the change in history documentation requirements answer your questions, or do you still want more information? Has your organization discussed changing documentation practices?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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