Knowledge Base Article

“Courage doesn’t happen when you have all the answers. It happens when you are ready to face the questions you have been avoiding your whole life.”
- Shannon L. Alder,

Last fall the American Hospital Association’s (AHA) released a Report detailing regulatory burden placed on hospitals, health systems and post-acute care (PAC) facilities. The report ended by noting “the outsized growth of staff and resources devoted to regulatory and compliance-related functions illustrates that a step back is needed: federal agencies should review and streamline requirements to reduce overhead cost of health care and allow providers to focus on their mission of caring for patients.”

You can read about the report in a related MMP article or by viewing a related AHA Infographic. It seems that CMS listened. This article focuses on how CMS is responding.

Patients over Paperwork

On October 26, 2017, CMS launched the “Patients over Paperwork” initiative. Through this initiative CMS has “established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience.”

CMS is keeping stakeholders informed through Patients over Paperwork Newsletters and the development of a Patients over Paperwork CMS webpage.

December 2017 Newsletter

In this inaugural edition, CMS noted that they have the following three aims for this initiative:

• Increase the number of satisfied customers – clinicians, institutional providers, health plans, etc. engaged through direct and indirect outreach;
• Decrease the hours and dollars clinicians and providers spend on CMS-mandated compliance; and
• Increase the proportion of tasks that CMS customers can do in a completely digital way.

CMS went on to outline how this initiative will work including having a Steering Committee, Customer Centered Workgroups, Journey Mapping, conducting listening sessions, reducing burden through rule making, and sub-regulatory changes.

January 2018 Newsletter

The second edition highlighted what CMS has been doing to reduce regulations, streamline requirements and improve clarity of guidance. Key efforts are presented in a “You Said” and “We Heard You” format and discusses the following areas of concern:

• Quality Measures,
• Quality Payment Program (QPP) (5522-FC),
• Appropriate Use Criteria for Advanced Diagnostic Imaging,
• Documentation Review,
• Quality and Safety Oversight,
• Promote Affordability for Consumers,
• States,

Specific to Documentation Review, there is a clarification related to Signature Requirements and Medical Review of Inpatient Rehabilitation Facility (IRF) Claims highlighted in the newsletter.

Clarified Signature Requirements

“Before: CMS contractors occasionally denied claims when a nurse initialed a medication administration log instead of including a full signature.

After: CMS clarified guidance in the Program Integrity Manual, such that providers ultimately responsible for the beneficiary’s care must sign the medical record; however, claims won’t be denied if a support care provider (such as a nurse documenting chemotherapy) doesn’t sign part of the record.

To Learn More, Visit: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R751PI.pdf”

Clarified Medical Review of Inpatient Rehabilitation Facility (IRF) Claims

“You Said: IRF claims are denied even though patients need and could benefit from an inpatient rehabilitation program.

We Heard You: CMS clarified guidance to its contractors, requiring them to use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case, and not based on any threshold of therapy time.

To Learn More, Visit: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE17036.pdf”

E/M Service Documentation Provided by Students (Manual Update)

Currently, a medical student may document review of systems (ROS) and/or past, family, and/or social history (PFSH)

While technically not credited as part of the Patients over Paperwork Initiative, a change to E/M service documentation provided by students is definitely in keeping with the Patients over Paperwork aims of increasing the number of satisfied customers (clinicians) and decreasing the hours clinicians spend on CMS-mandated compliance.

Effective January 1, 2018 with an implementation date of March 5, 2018, the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1 has been revised to update the policy on Evaluation and Management (E/M) documentation to allow teaching physicians to verity in the medical record any student documentation of components of E/M services, rather than re-documenting the work.

You can read more about this update in Change Request (CR) 10412 and related MLN Matters article MM10412.

Moving forward MMP plans to follow this initiative, keeping our readers informed about future Patients over Paperwork activities.