CMS Patients Over Paperwork E&M Coding Educational Video

– For over 20 years, federal rules of payment
on office visits have required
extensive documentation about body systems and organs that simply weren’t relevant
to the patient’s care. – Typically when I see
a patient and I go back and I write
my note on that patient, I have to first determine
how complex the care of that patient was
for that day. And so I have to choose
amongst five levels of coding. You probably know these as E/M codes
levels one through five. And so we have to determine
how complex the care of the patient was
to determine what level to bill. That’s actually not always
a very easy decision, is it? So if I decide that the patient
is pretty complex, level four or five,
then I then have to remember how many review of systems
I have to record in the chart; how many organ systems
on the physical exam I have to record
in the chart; how much of the patient’s
past medical history, family history, social history. – Electronic records
are largely filled with this type of boilerplate
templated text. – The proposed physician
fee schedule, if finalized, could bring about
a significant change that would help to reduce
documentation burden for clinicians treating
Medicare beneficiaries. – And it doesn’t actually change
the codes. It changes
the perverse payment incentives that are wrapped around
with these codes. – We are essentially collapsing
codes two through five, where you’ll get
one payment rate if you bill any of those codes
two, three, four, or five. And how does that affect
documentation? Well, that means that I really,
going forward, will document just the minimum that is needed
for the care of that patient. Then anything else
that I choose to document really can be focused on just
what is needed for that patient who is in front of me
at that time. – This means
that clinicians will be able to spend more time
with patients and document what truly matters
in the medical record in a way that meets
modern clinical practice. [upbeat music]