Despite Clinical Documentation Changes, ‘Note Bloat’ Remains

AHIMA August 28, 2023
John McCormack

In 2021, the Centers for Medicare and Medicaid Services (CMS) implemented new regulations, designed to reduce the administrative documentation burden associated with evaluation and management (E/M) Current Procedural Terminology (CPT) billing codes. The revisions to the code descriptors and documentation standards directly address the continuing problem of administrative burden for physicians in nearly every specialty. The changes are intended to move documentation for E/M office visits to center around how physicians think and take care of patients, instead of on mandatory standards that encourage copy/paste and checking boxes.

As such, a medically appropriate history and/or a physical examination are no longer required to select the level of service. These portions of documentation historically have added considerable “fluff” to clinical notes....

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