CMS 2019 Final Rule Aims to Reduce Documentation Time

The CMS 2019 final rule announced numerous updates, oriented toward reducing burdensome documentation and improving accuracy for outpatient evaluation and daily visits. This guidance literally changes how you should be documenting evaluations and daily visits.

After adjusting to the new CMS guidance, documentation time for Systems 4PT evaluations has declined by 50% (detail below). And most daily notes are now signed before the patient leaves the practice (note below). Meanwhile, compliance is precisely oriented toward the latest CMS guidelines.

As you’ll see below, there’s a lot to love about these changes.

Initial Evaluation: An Outtake from the CMS’ Final Rule

“ . . . for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary.”

Based on this CMS guidance, we have adjusted our evaluation workflow. Systems 4PT’s technology data mines our patient intake portal and recommends documentation for the following topics:

  • Medical History
  • Patient Concerns and Goals
  • Prior Level of Function
  • Employment Status
  • Impact on Employment or School
  • Outcome Test Name and Disability Index Score
  • Defensible Functional Deficits
  • MIPS BMI Counseling
  • MIPS Tobacco Counseling
  • MIPS Diabetes Neuro/Foot Exam
  • MIPS Falls Risk Counseling
  • MIPS Medications, Dosage, Frequency and Route of Intake
  • MIPS Pain at Best and Worst
  • Aggravating and Relieving Factors
  • Functional Goals
  • Complexities Related to The Patient’s Medical History
  • Complexities Related to The Exam Findings
  • Complexities Related to The Patient’s Clinical Presentation
  • Complexities Related to The Therapist’s Clinical Judgement
  • Defense of The Selected Eval Code Severity

In the blink of an eye, Systems 4PT recommends an average 1,250 patient-specific, MIPS-specific words in each evaluation.

Our workflow is fully-compliant with the 2019 CMS final, rule and lowers your eval documentation time an average:

  • 33 minutes faster than “check list EMR”
  • 24 minutes faster if you’re an average typist

The CMS has given you permission to spend less time typing and more time treating.

Daily Visit Documentation: An Outtake from the 2019 CMS Final Rule

“ . . . when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.”

Systems 4PT ’s daily notes are now oriented toward tracking the progression of the most clinically relevant deficit(s). Real-time integration with prior visits, prior episodes of care, and the patient portal enables you to document a fully compliant daily note in 90 seconds to 2 minutes, meaning:

When the daily visit is over, the note is signed.

And when it’s Sunday afternoon, you’re with your family and not with your EMR.

“I’ve treated patients for over 30 years. I’m not a computer guy, the whole thing is very intimidating.nBut I’ve GOT IT! After watching the training video, the new workflow it just clicked for me. For the first time in 30 years, I don’t have documentation homework! I’ve got it!”

—Russel S., Senior Therapist in a large, multi-state network.

Key Takeaways:

  1. Systems4PT cares about your patients

The CMS has given you permission to treat more and type less. Spending more time treating maximizes patient progression AND bolsters your reputation as the most hands-on, patient-oriented practice in the region. It’s a win-win!

  1. Systems4PT cares about you and your family

The rules have changed, but your EMR has not adjusted. With Systems4PT, you can cut your documentation time in half with improved compliance.

The CMS has given you permission to spend nights and weekends with your family instead of with homework.

We changed from the big web-based EMR to Systems4PT. About six weeks later, I looked over at my husband on a Sunday afternoon and said, “I just realized that it’s Sunday afternoon, and I’m not doing homework! There was no homework yesterday, and there isn’t any today. It just happened!

—Melinda S., Practice Owner

  1. Don’t let slow EMR negatively impact your life

If your car were unreliable and negatively impacted your nights and weekends, you would get a new car.

If your smartphone didn’t work, hurting your nights and weekends, you’d get a new phone.

You should take the same approach with your inefficient EMR. Rather than thinking of catching up on notes from home as “normal,” tell yourself, “This is unacceptable

Recommended Next Steps:

When you look at yourself in the mirror each morning, tell yourself, “I’m not going to let slow EMR waste my life.”


Take a look at our documentation videos. Watch us document an eval with twice the compliance in half the time.

At your convenience, document a Systems 4PT evaluation on your own computer. Our Hands-On Demo™ recommends an average 1,250 patient-specific, MIPS-specific words, in the blink of an eye, saving an average 24 minutes per eval.

Take a look at Systems 4PT over lunch, or before or after work. You’ll find our integrated scheduling, EMR, and billing software costs about 35% less than what you spend for your outdated EMR and billing today.

The CMS has given you permission to Treat More, Type Less.

Sign up to Learn How You Can

Reduce Your Documentation Time

Let’s talk about how S4PT can help your clinic get more!

Interested in a free demo of our products or business consultation tailored to your physical therapy clinic? Complete the form or call the number below today!

(814) 624–0084