Awareness : OBC Tips

Parts of the History Can Be Documented by Ancillary Staff or the Patient

Recently, the Centers for Medicare and Medicaid Services expanded the current policy for office/outpatient Evaluation and Management (E/M) visits.

Effective January 1, 2019, any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the patient does not need to be re-documented by the billing provider.  Once the information is documented, the billing provider can review the information, revise, update or supplement as necessary and initiate within the medical record that he/she has done so. 

To clarify terminology, we are using the term “history” broadly in the same way that the 1995 and 1997 E/M documentation guidelines use this term in describing the CC, Review of Systems (ROS) and Past, Family, Social History (PFSH) as “components of history that can be listed separately or included in the description of History of Present Illness (HPI).”