What documentation should in place before medical assistant give information to a third party?

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 receive payment for the service. Further, Medicare had not issued guidance on the allowability of patient entries into the medical record.

However, the Centers for Medicare and Medicaid (CMS) addressed these matters in the 2019 Calendar Year Physician Fee Schedule. Additional changes were made by CMS in 2021 that further simplified the requirements.

Physicians are required to redocument staff or patient entry in the patient record.*

Debunking the myth

Debunking the myth

Medicare documentation requirements changed in November 2018 and now allow physicians to “verify” in the medical record staff or patient documentation of components of E/M services, rather than redocumentation of the work, if this is consistent with state and institutional policies.

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.

Regulatory clarification

Regulatory clarification

Starting Jan. 1, 2021, the level of service is not determined by the history of present illness, social history, family history, review of systems or physical exam. These items may still warrant documentation for clinical purposes. There are no restrictions as to who can input this information into the patient’s record. Thus elements could be entered by the patient, a clerical assistant, a medical assistant or other clinician.

Summary of changes

Summary of changes

The 2021 Calendar Year Medicare Physician Fee Schedule allows a physician to determine the level of service based on either medical decision making (when billing by content) or by time. There is no requirement that the documentation be physically performed by the billing practitioner and no requirement to redocument information entered by a non-billing practitioner.

• Download this myth: Who can document components of E/M services? (PDF)
• Revisions to Payment Policies Under the Physician Fee Schedule and Other Revision to Part B for CY 2019. 83 FR 59452, mention at 59635. Centers for Medicare & Medicaid Services, November 23, 2018
• Evaluation and Management (E/M) Visit Frequently Asked Questions (FAQs) Physician Fee Schedule (PFS). Centers for Medicare & Medicaid Services, November 26, 2018

Debunking Regulatory Myths overview

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.

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