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Printed Date: 9/22/2015
The CY 2019 PFS final rule expanded current policy for office/outpatient E/M visits starting January 1, 2019, to provide that any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the beneficiary does not need to be re-documented by the billing practitioner. Instead, when the information is already documented, the billing practitioner can review the information, update or supplement it as necessary, and indicate in the medical record that he or she has done so. Ancillary personnel may enter all of the items, except the exam (excluding the vital signs) and the notations must be acknowledged as reviewed by the provider.
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Last Updated: 08/28/2019