and Management Documentation Guidelines: How Did We Get Here?
By Emily Hill, PA-C
Recent changes to the E/M document guidelines are only the
latest revisions to the patient visit codes and may be far
from the last.
Few nonclinical issues have created as much discussion, revision
and anxiety as the Evaluation and Management Services (E/M)
and their accompanying documentation
guidelines. The development of the guidelines began in 1994 and continues with
the release of yet another draft, known as the "June 2000 Documentation
In 1992, a complete restructuring of the codes used to describe patient visits
was published in Current Procedural Terminology (CPT) in response to
the implementation of Medicares physician fee schedule. It soon became
apparent that guidance was needed to clearly define the differences between
levels of service, and to encourage consistent coding.
This guidance took the form of guidelines issued by the Health Care
Financing Administration (HCFA) in September 1994, which introduced
the concept of "quantifying" certain
aspects of medical documentation to determine levels of service. The guidelines
were criticized, however, for not reflecting the focused work performed by
In response, the "1997 Documentation Guidelines" were developed to
reflect the clinical activities of specialists while maintaining work equivalency
for all physicians. Documenting and "counting" the number of specific
exam elements determined the level of examination. Because of concerns regarding
the complexity of the system, HCFA chose to delay implementation pending further
review and revisions. Medicare carriers were instructed to use both previous
sets of guidelines when reviewing medical claims.
Simultaneously, the CPT editorial panel drafted a revised version called
Framework," later called the "Proposed 1999 Documentation Guidelines." The
panel attempted to simplify the 1997 guidelines while continuing to quantify
certain aspects of the medical record.
Based on a technical assessment of the guidelines, HCFA recently concluded
that a new set was necessary to address the need for consistent medical record
review and the concerns of the medical community. In response, the June 2000
guidelines were developed by HCFA staff and are roughly based on the 1995 guidelines.
The most significant change is the inclusion of clinical examples that will
help in distinguishing levels of service. The examples will focus on commonly
seen patients and conditions, and will be central to the proper assignment
of levels of service.
The guidelines continue to be comprised of three main components: history,
exam and medical decision making, discussed below.
Changes in the history component of the guidelines will highlight medication
monitoring and reduce the amount of documentation required for a complete system
The history of the present illness (HPI) continues to be defined as either
brief or extended, but is not restricted to a description of current symptoms.
The types of HPI are distinguished by the amount of detail necessary to define
the problem and may include comments about previously diagnosed problems and
The requirements for a complete review of systems are reduced from documentation
of 10 organ systems to nine. However, the threshold for an extended review
is increased from two to three organ systems. Documentation of the past, family
and/or social history is virtually unchanged.
The types of physical exams are reduced to three and are classified as brief,
detailed or comprehensive. As with the 1995 guidelines, the number of body
areas or organ systems assessed defines the exam. The distinctions are determined
- Brief: findings
from one to two defined organ systems/body areas
- Detailed: findings
from three to eight defined organ systems/body areas
- Comprehensive: findings
from at least nine defined organ systems/body areas
There are no specific exam elements, and the extent of an individual system
exam is not defined. Reference is made to the specialty-specific examples
for appropriate documentation of single-system examinations.
Medical Decision-Making Component
Low, moderate and high define the types of medical decision making. Although
the concept for determining decision making is unchanged, the elements have
been reorganized. This new medical decision-making component includes three
diagnosis and amount/complexity of data reviewed
plan, including diagnostic and therapeutic tests, procedures
The elements within each area are described simply by adjectives such as limited,
complicated and moderate. The specialty-specific examples are intended
to provide guidance in using the decision-making component.
Time: The Alternative
The rules for using time as the controlling factor for the selection of the
level of service remain. The total length of the encounter is the only time
component that must be documented.
Two studies are planned before the guidelines are officially released. The
first will place equal weight on each of the three key components. This is
consistent with the current method of code selection. The second study will
place greater emphasis on medical decision making. The assumption is that decision
making may be a better indicator of physician work than the extent of the history
The pilot testing is scheduled to begin in spring 2001. An implementation date
for the revised guidelines is not yet known.
Despite the analyses, revisions and planned studies, the end may not yet be
in sight. HCFA has indicated that the June 2000 guidelines are only a first
step in a long process that will address concerns over the basic structure
and descriptors of E/M codes.
With E/M services representing approximately $18 billion in Medicare expenditures,
changes can be expected for a long time to come. Stay tuned for updates.
Emily Hill, PA-C is president of Hill & Associates, a national healthcare
consulting firm specializing in coding and compliance for physician practices.
Her e-mail address is Emily@codingandcompliance.com.
This article is derived from the McMahon Archives. This
information may be time sensitive and was archived on 5/23/2001