In the final rule for changes to the Medicare Physician Fee Schedule (MPFS) for 2019, the Centers for Medicare & Medicaid Services (CMS) finalized changes to the documentation requirements for office and other outpatient evaluation and management (E/M) services (99201–99205, 99212–99215) and for teaching physician documentation.

Each of the changes finalized in the MPFS are applicable only to the Medicare program unless adopted by states for their Medicaid programs and/or other government and private payer health plans. While most health plans have adopted Medicare E/M guidelines and related policies in the past, it is recommended that the most current policies of individual payers be reviewed and discussed with payer representatives prior to implementing these changes.

Changes effective January 1, 2019, under Medicare policy are as follows:

The CMS has removed the requirement that the medical record must document the medical necessity of furnishing the visit in the home...

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