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The Current Procedural Terminology (CPT) Editorial Panel of the American Medical Association has submitted its long-expected recommendations to the Health Care Financing Administration (HCFA) for revising its documentation guidelines for evaluation and management (E/M) codes. The E/M codes are used to report physician visits, consultations, and similar services.
The June 2 recommendations came about after many providers complained last year that HCFA's previous E/M proposal was too complicated and confusing.
"The major upside is the mechanical, bookkeeping approach of the old guidelines has been largely eliminated," says Catherine Fischer, a reimbursement policy advisor with Marshfield (WI) Clinic.
"The new proposed guidelines are much less rigid, more broad and fluid, than the 1995 and 1997 versions," she says. "This is a vast evolutionary improvement over many physicians' complaint that they often felt forced to do a lot of things they normally would not do, or need to do, simply to justify to an auditor why they charged for a certain level of service."
The potentially bad news, especially to HCFA, is that the new approach also makes it easier to justify a higher level of service — and higher bills. As such, the question now becomes: At a time when the Clinton administration is trying to restructure the Medicare program and reduce future health care spending, is it politically willing to accept a revised E/M coding system that could result in higher claims?
"This gets down to a basic issue of whether you design a coding system which can be easily used and gives the majority of honest docs some regulatory breathing room; or, do you go for a rigid approach whose main purpose is trying to prevent a few greedy providers from padding their claims?" says Fischer.
The basic changes in E/M policy recommended by the Editorial Panel include:
• Emphasize clinical communication as the primary role of the medical record and the need for confidentiality.
• Make requested revisions to the history, examination, and medical decision making guidelines components.
• Revise body system examination elements in the draft guidelines in response to specialty and other requests.
• Identify ways to reduce the role of "counting" of examination elements by emphasizing the importance of the actual CPT definitions and of using all pertinent information in the medical record that bears on the level of E/M code.
After another period of reviews, pilot tests, and refinements expected to last at least until the end of this year, HCFA is expected to propose replacing both the 1995 and 1997 E/M guidelines currently in use with the final revised version.
The following analysis provides a detailed account of how E/M codes should be approached and documented under the CPT Editorial Panel's June 2 proposal.
• Reviewing the level of service provided.
The level of service is intended to reflect the work involved in providing the service. Under the proposal, all of the key components (i.e., history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service for the following new or initial patient categories/ subcategories: office, new patient; hospital observation services; initial hospital care; office consultations; initial inpatient consultations; confirmatory consultations; emergency department services; comprehensive nursing facility assessments; domiciliary care, new patient; and home, new patient.
Two key components (i.e., history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E/M service for the following established or follow-up patient categories/subcategories: office, established patient; subsequent hospital care; follow-up inpatient consultations; subsequent nursing facility care; domiciliary care, established patient; and home, established patient.
The extent of the medical history depends on the physician's clinical judgment and the nature of the presenting problem(s) or the reason for the encounter.
If the physician is unable to obtain a sufficient history from the patient or other source within a clinically appropriate time frame, the record should describe the patient's medical condition or other circumstance that precludes obtaining a sufficient history. These may include:
• urgent/emergent condition(s);
• patient's inability to communicate;
• patient is at a very high level of risk, where immediate action is necessary;
• lack of interpreter;
• no medical record available;
• no family/significant other or legal guardian available in person or by telephone
Documenting the circumstances related to the inability to obtain a sufficient history will be considered the same as a comprehensive history for code selection purposes. However, this is only permitted for new patients, emergency department visits, initial hospital care codes, or patients new to the consulting physician.
CPT describes four types of history:
• problem focused;
• expanded problem focused;
Each type of history is made up, to varying degrees, of the following components:
• chief complaint or reason for the encounter;
• history of the present illness (HPI);
• review of systems (ROS);
• past, family, and/or social history (PFSH);
Any record format for documenting any component of the history (i.e., chief complaint/reason for encounter; history of present illness; review of systems; past, family, and/or social history) is acceptable, including, but not limited to, preprinted history forms completed by the patient, other informant, and/or ancillary staff, with documentation of review by the physician or other health care professional. (There must be a dated notation confirming, or supplementing as necessary, information recorded by others, including, but not limited to, preprinted history forms.)
Components may be identified separately, or they may be combined, for example, in the HPI. A single item of history should be considered either part of the HPI or the ROS but not both.
— Chief complaint and/or reason for encounter: This can include items such as referral by another physician, lab test performance, specific complaints, or physician directed return for follow-up. It must be easily inferred if not explicitly documented.
— History of present illness: The HPI may include positive and clinically pertinent negative statements describing different aspects of the presenting problem(s) (e.g., location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms, and related functional status descriptors).
HPI is documented as follows:
Brief HPI — statements about:
1. one to three items about the present illness(es)/presenting problem(s), OR
2. one or two present illness(es)/presenting problem(s), or chronic or clinically pertinent inactive conditions, in any combination.
Extended HPI — statements about:
1. at least four items about the present illness(es)/presenting problem(s), OR
2. at least three present illnesses/presenting problems, or chronic or clinically pertinent inactive conditions, in any combination.
— Review of systems: A review of systems obtained during an earlier encounter does not need to be re-recorded. Any new review of systems information should be documented, or alternatively document the lack of change (e.g., no change) from previous ROS with notation of date or location of previous ROS.
Review of systems is documented as follows:
Brief ROS — positive and/or negative responses for one to four systems.
Extended ROS — positive and/or negative responses for at least five systems.
For CPT coding purposes, the following systems are identified:
• constitutional symptoms (e.g., fever, weight loss);
• ears, nose, mouth, throat;
• integumentary (skin and/or breast);
— Past, Family, and/or Social History (Aller gic/ Immunologic): PFSH is documented as follows:
Brief PFSH — at least one item from any PFSH area.
Extended PFSH — at least one item from at least two of the three PFSH areas.
Past history — describes the patient's past experiences or lack thereof with illnesses, operations, injuries, and treatments, some examples of which are:
• listing and/or review of current medication(s);
• allergies (food, drug, and/or environmental);
• past illnesses and/or hospitalizations;
• pregnancy history;
• growth history;
• development history;
• immunization history;
• behavioral history;
• functional status history.
Other relevant past history — e.g., sexual history, gynecologic history, mother's history, newborns, birth history, school history, treatment/ medication compliance.
Family history — a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk, some examples of which are:
• cardiovascular disease (stroke, myocardial infarction or other cardiovascular illness);
• drug abuse;
• domestic violence and/or child abuse;
• metabolic/lipid disorders;
• hereditary disorders.
Social history — describes age-appropriate past and current activities. Some examples include:
• marital status;
• tobacco, alcohol, or drug use/abuse;
• employment status;
• occupational history;
• housing and/or source of drinking water;
• financial status;
• exercise patterns;
• diet history;
• travel history.
Other relevant social factors — a review of past, family, and/or social history obtained during an earlier encounter does not need to be re-recorded. Any new PFSH information should be documented, or "no change" from previous PFSH, with notation of date or location of previous PFSH, should be alternatively documented.
• Selecting the type of history.
All of the applicable history categories must be met for a given level of history, except that:
— Two of the three applicable history categories are sufficient for newborn infants.
— Two of the three applicable history categories are also sufficient for those levels of E/M services requiring a detailed or comprehensive interval history (e.g., 99231-99233, 99261-99263, 99301-99302, 99311-99313, 99331-99333, 99347-99350).
The chief complaint and/or the reason for the encounter is required for all codes except those that require only an interval history (e.g., subsequent inpatient hospital services).
Types of history:
Problem focused — brief one to three items about the present illness(es)/presenting problem(s) or one or two present illness(es)/presenting problem(s), or chronic or clinically pertinent inactive conditions, in any combination.
Expanded problem focused — brief one to three items about the present illness(es)/presenting problem(s) or one or two present illness(es)/ presenting problem(s), or chronic or clinically pertinent inactive conditions, in any combination.
Brief problem focused — positive and/or negative responses for one to four systems.
Detailed extended — at least four items about the present illness(es)/presenting problem(s) or at least three present illnesses/presenting problems, or chronic or clinically pertinent inactive conditions, in any combination.
Detailed brief — positive and/or negative responses for one to four systems.
Brief — at least one item from any of the three PFSH areas.
Comprehensive extended (HPI) — at least four items about the present illness(es)/presenting problem(s) or at least three present illnesses/presenting problems, or chronic or clinically pertinent inactive conditions, in any combination.
Comprehensive extended (ROS) — positive and/or negative responses for at least five systems.
Extended — at least one item from at least two of the three PFSH areas.
CPT describes four types of examinations:
— problem focused;
— expanded problem focused;
These examinations may be a general multisystem examination, the examination of a single body area or organ system, or any combination thereof. Any examination may be performed by any physician regardless of specialty. Actual content of the examination is selected by the examining physician in accordance with the needs of the patient.
The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of examinations, defined as follows:
Problem focused examination — a limited examination of the affected body area(s) or organ system, which typically includes one to five exam items.
Expanded problem focused examination — a limited examination of the affected body area(s) or organ system and other clinically relevant or related body area(s) or organ system(s), which typically includes six to 11 exam items.
Detailed examination — an extended examination of the affected body area(s) and other clinically relevant or related body area(s) or organ system(s), which typically includes 12 to 17 exam items.
Comprehensive examination — a general multisystem examination or a complete examination of a single organ system and other clinically relevant body area(s) or organ system(s). Note: The comprehensive examination performed as part of the preventive medicine evaluation and management service is multisystem, but its extent is based on age and pertinent risk factors. It typically includes 18 or more exam items (within the constraints imposed by the urgency of the patient's mental status and/or clinical condition).
Any type of record format is acceptable, including, for example, simple checklists to indicate that an item has been performed.
If a checklist or template includes descriptors of distinct elements but also includes an indicator that the entire group was normal or negative, a notation to indicate all indicated elements were examined suffices. In this approach, elements not actually performed should be crossed out or otherwise indicated.
A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings.
Specific abnormal and clinically relevant negative findings should be documented. A notation of "abnormal" without elaboration is insufficient. For subsequent visits, a notation of "unchanged" in a previously abnormal finding is adequate.
• Simplified documentation.
Simplified documentation of a single body area and/or organ system is acceptable and is equivalent to performance of a single examination item. The exception is head, eyes, ear, nose, and throat, where organ systems are grouped collectively. For example, examination of the head, eyes, ear, nose, and throat will be equivalent to three examinations, as this includes several organ systems.
• Medical decision making.
CPT describes four levels of medical decision making. For purposes of documentation, three levels are considered:
— low complexity (encompasses straightforward complexity);
— moderate complexity;
— high complexity.
Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as reflected by:
— the scope of the presenting problem(s), number of diagnoses considered, and/or risk of complications, morbidity or mortality;
— diagnostic procedures/tests ordered and/or the amount of data to be obtained or reviewed;
— management options considered.
(Editor's note: A full version of the report can be found on the Internet at: www.ama-assn.org/emupdate/ mso292.doc.)