Debunking regulatory myths

AMA’s regulatory myths series provides physicians and their care teams with resources to reduce guesswork and administrative burdens so the focus can be on streamlining clinical workflow processes, improving patient outcomes and increasing physician satisfaction.

The AMA provides regulatory clarification to physicians and their care teams in an effort to aid physicians in their day-to-day practice environment. 

1. Depression screening

   1. Is time documentation required for Medicare depression screenings?

2. “Break-the-Glass” EHR functionality

   1. Are “Break-the-Glass” functions required for employee EHR access?

3. Responding to patient portal messages

   1. Can non-physician care team members respond to patient messages?

4. Double billing at federally qualified health centers (FQHCs)

   1. Can FQHCs bill for more than one visit on the same day per patient?

5. Entering a diagnosis and procedure code

   1. Are only physicians and other billing health care professionals allowed to enter or change diagnosis and procedure codes?

6. Use of note templates for documenting medical information

   1. Does CMS prohibit the use of note templates?

7. Advance care planning at Medicare visits

   1. Is advance care planning required at every Medicare patient visit?

8. Adherence to Joint Commission standards

   1. Are organizations only held accountable to Joint Commission standards?

9. Chronic care management consent

   1. Is consent for chronic care management required regularly?

10. Impact of vital signs on level of service billed

    1. Does the number of vital signs recorded affect billing?

11. Two-factor authentication for prescriptions

    1. Is two-factor authentication required for all prescriptions?

12. Review of patient test results

    1. Must all test results be reviewed by patients’ primary care physician?

13. Admission, discharge and transfer (ADT) messages

    1. Are hospitals required to deliver ADT notifications directly to a physician’s EHR inbox?

14. EHR gag clauses

    1. Can physicians openly discuss EHR issues?

15. Protected health information (PHI) disclosures

    1. Does HIPAA require that health care providers obtain patient authorization to disclose PHI for treatment purposes?

16. Mental health

    1. Are licensing/credentialing bodies required to probe into past mental health or substance use?

17. Home health agency plan of care (POC) certification

    1. How should physicians sign home care plan of care certifications and recertifications? 

18. Documenting time for each task during outpatient visits

    1. Are physicians and other qualified health professionals required to document the time spent on each specific task associated with an outpatient visit?

19. Online patient reviews

    1. Are physicians prohibited from responding to online patient reviews?

20. Preventive/wellness and evaluation and management (E/M) services

    1. Can physicians bill for both preventive and E/M services in the same visit?

21. EHR documentation

    1. Are clinical support staff required to log out of EHR between documentation?

22. Verbal orders

    1. Are verbal orders prohibited?

23. Ancillary staff and/or patient documentation

    1. Who can document components of E/M services?

24. Computerized Provider Order Entry (CPOE)

    1. Is order entry a physician-only EHR task?

25. Food and drink contamination in work spaces

    1. Who determines where physicians and other health care workers can eat or drink while at work?

26. Student documentation

    1. Are teaching physicians required to re-document the EHR work of students?

27. Pain assessments

    1. Are clinicians required to ask patients about pain during every visit?

Stay up to speed on how state and federal law apply to health insurer-related issues.