Evaluation 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 Guidelines."

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 Medicare’s 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 specialists.

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 the "New 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.

History Component
Changes in the history component of the guidelines will highlight medication monitoring and reduce the amount of documentation required for a complete system review.

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 medication management.

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.

Exam Component
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 as follows:

  • 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 broad areas:

  • Severity/urgency of illness
  • Differential diagnosis and amount/complexity of data reviewed
  • Treatment plan, including diagnostic and therapeutic tests, procedures and interventions.

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.

Next Steps
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 or exam.

The pilot testing is scheduled to begin in spring 2001. An implementation date for the revised guidelines is not yet known.

Final Step
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

This article is derived from the McMahon Archives. This information may be time sensitive and was archived on 5/23/2001