New Coding Requirements Result in Reduced EHR Documentation Time for Doctors

Coding Requirement Reduced EHR Burden

According to a research letter published in top journal, the attempt by Centers for Medicare & Medicaid Services (CMS) to alleviate the EHR documentation burden on physicians has not yielded the anticipated outcomes.

At the beginning of 2021, Centers for Medicare & Medicaid Services (CMS) revised the evaluation and management (E/M) coding requirements for outpatient visits, eliminating the need for history and physical exam documentation. The agency made a prediction that this alteration would result in an average reduction of 19 seconds in documentation time per visit. To evaluate the impact of these changes, a team of researcher’s analyzed EHR documentation time among over 18,000 physicians nationwide from September 2020 (prior to the changes) through the end of 2021. The study included clinicians who used the Cerner Lights on Network EHR.

The authors of the research letter concentrated on four medical specialties with varying E/M volume, including family and internal medicine (both of which have a high volume), cardiology (moderate volume), and orthopedics (low volume). They assessed the time taken to document notes in minutes per visit, which was determined by frequent software, keyboard, and mouse actions.

The researchers discovered that within four months of the change, the mean documentation time remained unchanged for three specialties: internal medicine, cardiology, and orthopedics. However, family medicine physicians experienced a 4.8-second increase in documentation time.

During the period from May 2021 until the end of the study, the researchers observed “minor reductions in documentation time…that were not clinically significant” for all specialties. The reductions in documentation time were 16.2 seconds for internal medicine, 13.8 seconds for family medicine, 12.6 seconds for cardiology, and 6.6 seconds for orthopedics.

The study had limitations, including its focus on a single EHR vendor and the inability to distinguish between times spent on different documentation domains. The authors suggested that the reductions in documentation time in domains impacted by CMS regulations may have freed up time for more valuable documentation.

The authors of the study further expressed that, regardless of whether the overall documentation time is noticeably reduced, the revised E/M requirements have the potential to alleviate physicians’ cognitive burden and improve their work experience.