For the first time in many years, there are rules regarding new Medicare documentation changes that are actually good news!

In fact, for the first time in…well, forever…the latest changes proposed by Medicare will actually make chiropractic documentation easier in respect to your Evaluation & Management (E/M) notes.  Here’s why:

New E/M Medicare Documentation Changes for 2019

Medicare had originally proposed to overhaul the entire E/M coding and documentation system for 2019, but those plans were delayed and dismissed.  However, what did emerge from the analysis of the E/M codes was a streamlining of the documentation requirements that resulted in new Medicare documentation changes.

On November 1, 2018, Medicare released its “Final Rule” regarding the E/M documentation guideline changes for office/outpatient visits which will go into effect January 1, 2019 (as well as a number of other changes). Here are the details on the E/M guidelines:

History and Exam Documentation 

The current Medicare E/M documentation guidelines (both the 1995 and 1997) allow for a previously obtained ROS (Review of System) and/or PFSH (Past, Family and Social history) of an established patient, in an institutional setting or group practice where providers use a common record, to be reviewed and updated without having to re-record the documentation.

Specifically, the rule states that: “the review and update may be documented by:

  • describing any new ROS and/or PFSH information or noting there has been no change in the information; and
  • noting the date and location of the earlier ROS and/or PFSH.

However, effective January 1, 2019, Medicare will expand on this, and include exam documentation. Per the final rule, CMS states:

When relevant information is already contained in the medical record, practitioners would only be required to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting a defined list of required elements such as review of a specified number of systems and family/social history.

Practitioners would still review prior data, update as necessary, and indicate in the medical record that they had done so. Practitioners would conduct clinically relevant and medically necessary elements of history and physical exam, and conform to the general principles of medical record documentation in the 1995 and 1997 guidelines. However, practitioners would not need to re-record these elements (or parts thereof) if there is evidence that the practitioner reviewed and updated the previous information.

Accordingly, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.

In addition, the new rule expands documentation requirements to allow the chief complaint and history (for both new and established patients) to be entered by the ancillary staff and/or patients.

Quick Summary of Changes in Plain English

If we skip past the confusing language of Medicare, here is what this will mean for you:

  • You will be able to document your exams more easily and more quickly by not having to repeat information in your notes just for the sake of meeting coding requirements.
  • You will be able to have staff and/or patients participate in the process of making your documentation faster and easier

The Impact Beyond Medicare

Even though Medicare does not pay chiropractic physicians for E/M codes, these changes can still significantly impact your practice because of one very important fact: the current coding and documentation system in place for ALL payers is based on Medicare’s interpretation of the E/M guidelines.

In other words, it is highly likely that EVERY insurance payer will follow these guidelines for their own plans!

Furthermore, unless your state specifically forbids delegating any services to ancillary personnel, these changes will impact multiple payers, but have the potential to do so in every state.


Keep alert for more detailed commentary (from Medicare and beyond) on these new requirements for info on how to implement them into your current practice procedures.

Get ready for more changes coming from Medicare (not all good) that we’ll cover in a future post.

If you want to dive deeper on these Medicare change – and more private payer insurance changes as well –get the RECORDING of our Chiropractic Insurance Billing, Coding & Documentation MASTERY seminars so you don’t miss out!