This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.
Debunking the myth
As of November 2018, staff and patient documentation of components of E/M services may be used in clinical documentation and physicians may “verify” the documentation in the medical record rather than repeating this work.1,2
In January 2021, Medicare documentation requirements were further simplified: when billing by content (as opposed to time), medical decision making is the only component that drives the level of service determination.1,2
Background
Ancillary staff and/or patient documentation is the process of non-physicians and non-advanced practice providers (APPs) documenting clinical services, including history of present illness (HPI), social history, family history and review of systems in a patient’s electronic health record (EHR).
Historically, Medicare required the physician to redocument ancillary staff’s entries of the HPI to support billing for the service. Further, Medicare had not issued guidance on the allowability of patient entries into the medical record.
The Centers for Medicare and Medicaid Services (CMS) addressed these matters in the 2019 Calendar Year Physician Fee Schedule, and further simplified the documentation requirements for billing in 2021.
Additional information
As of January 1, 2021, the level of service for E/M encounters is not determined by the history of present illness, social history, family history, review of systems, or physical exam. These components may still be needed and documented for clinical purposes, but the level of service is based on medical decision-making alone or the amount of time spent by the physician on the day of service. This means physicians only need to include documentation of the data pertinent to the care of the patient on the day of the visit. There are no restrictions as to who can input this information into the patient’s record. Thus, elements can be entered by the patient, a clerical assistant, a medical assistant, or other clinician.1,2
Key takeaway
Collaborating with ancillary staff—and even patients—to document in the medical record, as opposed to redocumenting this information, can reduce burnout by increasing the time physicians spend caring for patients and decreasing the time they spend on documentation.
Success story
In a national longitudinal cohort study, over 18,000 ambulatory physicians were studied over a 9-month period to determine how the adoption of team-based documentation impacts physician visit volume and time spent documenting in the EHR. Team-based documentation included the physical presence of a medical scribe in the room, use of a virtual note-taking service, and sharing of note-taking responsibilities with non-physician care team members. 3
Findings revealed that when physicians used teamwork to complete their notes, they were able to spend more time with patients and less time in the EHR. Specifically, visit volume increased by an average of 6% and documentation time decreased by an average of 9.1%. For physicians that utilized team-based documentation to complete over 40% of their notes, an even greater impact was observed—weekly documentation time was reduced by over an hour (amounting to a 28.1% decrease).3
Resources
- AMA STEPS Forward® Toolkit: Team-Based Care. Accessed December 2024.
- AMA Private Practice Simple Solutions Webinar: Team Documentation. Accessed December 2024.
- AMA STEPS Forward Podcast: Team-Based Care Model. Accessed December 2024.
References
- Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS). 83 FR 59452.; 2018. Accessed December 9, 2024. https://www.govinfo.gov/content/pkg/FR-2018-11-23/pdf/2018-24170.pdf
- Centers for Medicare & Medicaid Services (CMS). Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019.; 2018. Accessed December 9, 2024. https://www.federalregister.gov/documents/2018/11/23/2018-24170/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions
- Apathy NC, Holmgren AJ, Cross DA. Physician EHR Time and Visit Volume Following Adoption of Team-Based Documentation Support. JAMA Intern Med. 2024;184(10):1212. doi:10.1001/jamainternmed.2024.4123
Debunking Regulatory Myths overview
Visit the overview page for information on additional myths.
Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.