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EHR Documentation Time Dips After CMS E/M Coding Changes

While EHR documentation time has decreased since CMS changed its E/M coding requirements in 2021, the degree of reduction is less than CMS estimated.

Clinician EHR documentation time went down slightly following changes to Centers for Medicare & Medicaid Services (CMS) outpatient evaluation and management (E/M) coding requirements, according to a research letter published in JAMA Health Forum.

On January 1, 2021, CMS modified outpatient E/M coding requirements in an effort to reduce documentation burden. Changes to the requirements included the elimination of history and physical examination documentation.

In a national cohort study, researchers assessed active EHR notes documentation time across all healthcare organizations using the Oracle Cerner Lights On Network EHR from September 2020 through December 2021.

The study limited analyses to four specialties with varied E/M volume: family medicine (high volume), internal medicine (high), cardiology (moderate), and orthopedics (low). The researchers assessed active EHR notes documentation time based on frequent software, keyboard, and mouse actions in minutes per visit.  

While the study found small reductions in documentation time following the changes in CMS E/M coding requirements, the decrease was not clinically significant.

These findings echo another study that found a small decrease in EHR documentation time across the Epic Signal database post-implementation of the new CMS coding requirements.

The degree of reduction was modest in both studies, coming in less than the 19-second CMS-estimated reduction in documentation time per visit.

The authors noted that the study has several limitations, including its focus on a single EHR vendor. Additionally, the study did not distinguish time spent on different documentation domains.

“It is possible that reductions in documentation in the domains affected by the CMS regulations freed up time that physicians used for higher-value documentation in other domains, which could explain the sizeable physician-level variation we found,” the study authors suggested.

“Even if total documentation time is not dramatically reduced, the scaled-back E/M requirements could reduce physicians’ cognitive burden and improve their work experience,” they added.

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