{"id":9707,"date":"2019-08-07T12:19:40","date_gmt":"2019-08-07T06:49:40","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=9707"},"modified":"2025-08-21T12:04:23","modified_gmt":"2025-08-21T12:04:23","slug":"pop-for-simplifying-documentation-requirements","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/pop-for-simplifying-documentation-requirements\/","title":{"rendered":"POP for Simplifying Documentation Requirements"},"content":{"rendered":"<h3 style=\"text-align: left;\"><strong>A patient over Paperwork (POP) Initiative<\/strong><\/h3>\n<p style=\"text-align: left;\">Through \u2018Patients over Paperwork,\u2019 CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, increase efficiencies, and to improve the beneficiary experience. As part of the Patients over Paperwork Initiative, Medicare is simplifying documentation requirements so that providers spend less time on paperwork, allowing them to focus more on patients and less on confusing and time-consuming claims documentation. CMS made the following important changes:<\/p>\n<ul style=\"text-align: left;\">\n<li><strong>Clarified acceptable documentation for diagnostic laboratory tests<\/strong><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong> CMS provided no instructions about how much information was required in the medical record to show a physician\u2019s intent to order lab tests.<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> A signed order, a signed requisition or a signed medical record that supports the <a href=\"https:\/\/www.medicalbillersandcoders.com\/physician-group.aspx\">physician<\/a>\/practitioner\u2019s intent to order tests (e.g. \u2018order labs, \u2018check blood\u2019, \u2018repeat urine\u2019) can satisfy the order requirements for labs.<\/p>\n<ul style=\"text-align: left;\">\n<li><strong>Provided an exception so that physicians acting as suppliers do not need to write orders to themselves.<\/strong><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong>\u00a0 The manual did not provide an exception to the written order requirements for physicians that provide DMEPOS to their own patients (in accordance with self-referral laws).<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> A physician acting as a supplier does not need to write to him\/herself an order. We will consider any medical documentation (e.g., progress note) with all necessary information as meeting the requirements for an order.<\/p>\n<ul style=\"text-align: left;\">\n<li>\n<p style=\"text-align: justify;\"><strong>Eliminated the requirement that physicians indicate wherein the medical record certification\/recertification elements can be found.<\/strong><\/p>\n<\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong> Information contained in other provider records, such as physicians\u2019 progress notes, need not be repeated in the certification or recertification statement itself. However, the regulation required physicians to note page numbers where that information could be found.<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> Physicians do not need to reference page numbers in their certification or recertification statements.<\/p>\n<ul style=\"text-align: left;\">\n<li>\n<p style=\"text-align: left;\"><strong>Explained that a signature and date is acceptable verification of a medical student\u2019s documentation of an E&amp;M visit performed by a physician <\/strong><\/p>\n<\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong> As of January 1, 2018, a teaching physician does not have to re-document a medical student\u2019s notes of an E&amp;M visit, but can verify them. Our instructions didn\u2019t specify what acceptable verification is for medical review purposes.<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> If a teaching physician chooses to rely on the medical student documentation and chooses not to re-document the E&amp;M service, contractors will consider this requirement met if the teaching physician signs and dates the medical student\u2019s entry in the medical record.<\/p>\n<ul style=\"text-align: left;\">\n<li><strong>Simplified the requirements for preliminary\/verbal DMEPOS orders<\/strong><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong> CMS provided no clear instructions about whether preliminary (verbal) orders for DMEPOS items were conditions of payment.<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> Suppliers may dispense most items of DMEPOS based on a verbal order or preliminary written order from the treating physician. However, <a href=\"https:\/\/www.medicare.gov\/\">Medicare<\/a> medical review contractors will look to the signed, written order to see if the item meets our payment requirements.<\/p>\n<ul style=\"text-align: left;\">\n<li><strong>Clarified DMEPOS written order prior to delivery date requirements<\/strong><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong> There was confusion about whether contractors needed to verify that a written order was received by checking for a fax transmittal date or a date stamp.<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> If the written order is dated the day of or prior to delivery there\u2019s no need for affirmative documentation of its being \u2018received\u2019.<\/p>\n<ul style=\"text-align: left;\">\n<li><strong>Clarified proof of delivery (POD) requirements<\/strong><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong> The <a href=\"https:\/\/www.medicalbillersandcoders.com\/0-0-durablemedicalequipment-medical-billing.html\">Durable Medical Equipment (DME)<\/a> Medicare Administrative Contractors (MACs) help CMS oversee the DME benefit. Some DME MACs were routinely auditing suppliers for proof of delivery for every claim they reviewed. Suppliers maintain proof of delivery but often fail to meet a technical requirement necessary for compliance.<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> New guidance advises MACs to request proof of delivery documentation for DME items only if it is required as a condition of payment, for example, as a written order prior to delivery for Power Mobility Devices. The guidance also simplifies CMS documentation instructions. While suppliers are still required to keep proof of delivery for every item they bill and may be requested to provide such documentation to other review entities, this should reduce the number of paperwork suppliers is required to submit to MACs during the medical review.<\/p>\n<ul style=\"text-align: left;\">\n<li><strong>Clarified signature requirements<\/strong><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong> CMS contractors denied claims when a nurse initialed a medication administration log instead of including a full signature.<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> We&#8217;ve clarified guidance to explain that providers ultimately responsible for the beneficiary&#8217;s care must sign the medical record. Claims won&#8217;t be denied if a support care provider, such as a nurse documenting chemotherapy, doesn&#8217;t sign part of the record.<\/p>\n<ul style=\"text-align: left;\">\n<li><strong>Clarified medical review of inpatient rehabilitation facility (IRF) claims<\/strong><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong> IRF claims were denied even though patients needed and could benefit from an inpatient rehabilitation program.<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> CMS clarified guidance to its contractors, requiring them to use clinical review judgment to determine the 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.<\/p>\n<ul style=\"text-align: left;\">\n<li><strong>Clarified billing for Immunosuppressive Drugs<\/strong><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong>\u00a0 If a supplier mailed an immunosuppressive drug shortly before the end of a beneficiary\u2019s inpatient stay and used the mailing date as the date of service, the claim could be rejected. This happened because the claim\u2019s date of service preceded the beneficiary\u2019s date of discharge.<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> We clarified that a supplier can use the discharge date as the date of service if mailing one or two days before discharge.<\/p>\n<ul style=\"text-align: left;\">\n<li><strong>Allowed teaching physicians to verify student\u2019s Evaluation and Management visit notes<\/strong><\/li>\n<\/ul>\n<p style=\"text-align: left;\"><strong>Before:<\/strong> Teaching physicians had to re-document most updates even when they concurred with what the medical student wrote in the patient\u2019s medical record.<\/p>\n<p style=\"text-align: left;\"><strong>After:<\/strong> We revised the manual instructions to allow teaching physicians to verify in the medical record any student documentation of billable services, rather than re-documenting the work.<\/p>\n<h2 style=\"text-align: left;\">FAQs:<\/h2>\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1755777785258\"><strong class=\"schema-faq-question\">1. What is the Patients Over Paperwork (POP) Initiative?<\/strong> <p class=\"schema-faq-answer\">The POP Initiative aims to streamline CMS regulations to reduce unnecessary burdens on healthcare providers, allowing them to focus more on patient care instead of paperwork.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1755777801429\"><strong class=\"schema-faq-question\">2. How has CMS simplified documentation requirements for lab tests?<\/strong> <p class=\"schema-faq-answer\">Providers can now satisfy lab test order requirements with a signed order, requisition, or relevant documentation showing intent, eliminating previous ambiguity.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1755777810905\"><strong class=\"schema-faq-question\">3. What change was made regarding DMEPOS orders for physicians acting as suppliers?<\/strong> <p class=\"schema-faq-answer\">Physicians no longer need to write orders to themselves; any relevant medical documentation can serve as an order, simplifying the process.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1755777819480\"><strong class=\"schema-faq-question\">4. What clarification was provided for proof of delivery (POD) requirements?<\/strong> <p class=\"schema-faq-answer\">CMS now requires proof of delivery documentation for DME items only when necessary for payment, reducing the paperwork burden for suppliers.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1755777836410\"><strong class=\"schema-faq-question\">5. How do the changes affect teaching physicians verifying medical student notes?<\/strong> <p class=\"schema-faq-answer\">Teaching physicians can now verify medical student documentation without needing to re-document, streamlining the process and reducing redundant work.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>A patient over Paperwork (POP) Initiative Through \u2018Patients over Paperwork,\u2019 CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, increase efficiencies, and to improve the beneficiary experience. As part of the Patients over Paperwork Initiative, Medicare is simplifying documentation requirements so that providers spend less time on [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":19754,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[65],"tags":[1807,1808,1809,1810,1811,1812,1813,1814,1815,1816,1817,1818,1819],"class_list":["post-9707","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-practice-management","tag-a-simplified-formulation-of-predictive-object-points","tag-claim-submission-and-processing","tag-cms-audit-success-health-care-compliance-association","tag-cms-performance-improvement-requirements","tag-cms-proposes-to-simplify-coding-and-documentation","tag-cms-says-it-will-reduce-documentation-coding-requirements","tag-cms-tries-to-simplify-e-m-code-subjectivity","tag-cms-update-on-medical-record-documentation-for-e-m-services","tag-e-m-coding-and-documentation-guidelines","tag-implementing-cms","tag-optimize-your-documentation-to-improve-medicare","tag-prepare-for-major-changes-to-e-m-coding","tag-simplifying-documentation-requirements"],"yoast_head":"<!-- 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The main goal of our organization is to assist physicians looking for billers and coders, at the same time help billing specialists looking for jobs, reach the right place.\"},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/pop-for-simplifying-documentation-requirements\\\/#faq-question-1755777785258\",\"position\":1,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/pop-for-simplifying-documentation-requirements\\\/#faq-question-1755777785258\",\"name\":\"1. 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