Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
Chest. 2020 Jul;158(1):298-302. doi: 10.1016/j.chest.2020.01.028. Epub 2020 Feb 10.
Guidelines for clinical documentation of evaluation and management face-to-face services were developed > 20 years ago. Recently, the Centers for Medicare & Medicaid Services (CMS) have addressed office and other outpatient services and the corresponding reimbursement, intending to reduce the amount of required documentation and to alleviate clerical burden. A CMS final rule for 2021 will eliminate the history and physical examination as criteria for level of service, allow time or medical decision-making to be used as coding criteria, and will recognize a code for prolonged service. The net effect of these changes may be some decrease in documentation burden, a change in the composition of clinical notes, and greater recognition by CMS of primary care and those who see highly complex patients requiring prolonged services.
20 年前就制定了评估和管理面对面服务的临床文档记录指南。最近，医疗保险和医疗补助服务中心（CMS）已经解决了办公室和其他门诊服务以及相应的报销问题，旨在减少所需文档的数量并减轻文书工作负担。CMS 针对 2021 年的最终规定将取消病史和体检作为服务水平的标准，允许使用时间或医疗决策作为编码标准，并将为延长服务制定一个代码。这些变化的最终结果可能是文档负担的一些减少，临床记录组成的变化，以及 CMS 对初级保健和那些看高度复杂需要延长服务的患者的更大认可。
