How Are We Simplifying Documentation Requirements?

CMS is working to clarify, simplify, or eliminate confusing and unnecessary documentation requirements. We continue to solicit suggestions for improvement from internal and external stakeholders. Below are the most recent changes and updates:

You told us:

Action taken to reduce burden:

Provided an exception so that physicians acting as suppliers do not need to write orders to themselves: The manual did not provide an exception to the written order requirements for physicians that provide DMEPOS to their own patients (in accordance with self-referral laws).

A physician acting as a supplier does not need to write him/herself an order. We will consider any medical documentation (e.g., progress note) with all necessary information as meeting the requirements for an order.
Read this Medicare Learning Network article to learn more.

Eliminated the requirement that physicians indicate where in the medical record certification/recertification elements can be found: Information contained in other provider records, such as physicians’ progress notes, need not be repeated in the certification or recertification statement itself. However, regulation required physicians to note page numbers where that information could be found.

Physicians do not need to reference page numbers in their certification or recertification statements.
Read the change.

Explained that a signature and date is acceptable verification of a medical student’s documentation of an E&M visit performed by a physician: As of January 1, 2018 a teaching physician does not have to re-document a medical student’s notes of an E&M visit, but can verify them. Our instructions didn’t specify what acceptable verification is for medical review purposes.

If a teaching physician chooses to rely on the medical student documentation and chooses not to re-document the E&M service, contractors will consider this requirement met if the teaching physician signs and dates the medical student’s entry in the medical record.
Read this Medicare Learning Network article to learn more.

How Can I Provide Feedback?

Please send suggestions about what documentation requirements we can improve to ReducingProviderBurden@cms.hhs.gov. Visit our webpage on simplifying documentation requirementsfor more information. You may also visit our Center for Program Integrity events webpage to connect with us in person, via webinar, or on one of our national calls.