Anesthesia Coding Alert

One of the biggest coding news items for the summer and fall was the introduction of new evaluation and management (E/M) guidelines for physicians. The Health Care Financing Administration (HCFA) introduced a draft of the guidelines in late June, and physicians, associations and coding professionals have since shared input with HCFA. All anesthesia providers and coders, especially those who use E/M codes frequently to report pain management, pretransplant consults or other specialized services, should be aware of the new guidelines and keep updated on the status of their implementation.

So Whats Different?

The new guidelines are designed to clarify and simplify documentation requirements. As HCFA acknowledges, many physicians find documentation to be burdensome and may be receiving improper compensation because of inadequate documentation. In an open letter to physicians published in the Journal of the American Medical Association, HCFA Administrator Nancy-Ann DeParle stated, It is not unusual for well-intentioned physicians to code as much as two levels apart for identical services because of varying interpretations of definitions of histories, physicals and medical decision- making (MDM) in the CPT-4 coding system used for filing claims.

The letter continued to explain that HCFA planners determined that it was more agreeable to the medical community to start over with three goals in mind: simplify the guidelines, reduce the burden and foster consistent and fair medical review.

Differences in Documentation

Only pain management providers (or providers who choose to bill for E/M services for pre-op evaluations when the intended procedure is canceled) will be significantly affected by the proposed new guidelines because regular anesthesia services do not require this type of documentation. Some of the major changes between existing guidelines and the new draft version include:

The problem-focused and expanded problem- focused exams have been combined into one brief exam for documentation purposes. The new categories of physical exams are based on the number of organ systems examined rather than the total number of items examined. A brief exam includes one to two body areas or organ systems, and a detailed exam includes findings from three to eight organ systems. A comprehensive multisystem exam includes findings from nine or more of the seven body areas or 13 organ systems, or at least three constitutional findings comparable to one body area or organ system. For example, a brief exam could include a pain service visit for multiple rib fractures. A detailed exam could include evaluation of leg pain, and a comprehensive exam could include evaluation of a patient with signs of sepsis.

Counting of elements in an exam is virtually eliminated. The 1997 documentation guidelines provided specific bullet items for each single specialty exam, explains Charla Prillaman, CPC, senior coding consultant with Webster, Rogers, and Co., LLP, a medical billing service in Florence, S.C. Definitions are precise numbers, and there is a very confusing requirement in reference to the comprehensive single specialty exam things like document all the bullets in a shaded area and one in each of the unshaded areas. The general multisystem exam at the comprehensive level requires that you perform all and document two bullets in each of nine organ systems. The new guidelines eliminate the bullets and shading, which reduces the number of elements to be counted.

The patients progress, response to, and changes in treatment and diagnosis have always been documented. Now the patients planned follow-up care and instructions also must be included in the documentation.

Any additions to the patients medical record (such as lab or other diagnostic test results) should be dated the day the information is added to the patients record rather than the date the service was provided.

The timeliness of service is stressed more in the new guidelines. All services should be documented during the patients visit or as soon after it is provided as practical to maintain an accurate medical record.

Documentation of the patients history also has been simplified. The 1995 and 1997 guidelines both permitted a summary statement of review of systems to count toward the comprehensive history level. The proposed guidelines require that each system reviewed be mentioned individually.

The proposed guidelines clearly state that the confidentiality of the medical record should be fully maintained consistent with the requirements of medical ethics and law.

Differences in Medical Decision-making

MDM refers to the complexity of determining a diagnosis and/or selecting a management option for a patient. The major change related to MDM in the draft guidelines is the restructuring of levels: Straightforward decision-making has been eliminated, so the proposed guidelines now have only three levels of MDM (low, moderate or high complexity).

Examples of the new types of MDM services related to anesthesia practices could include:

Low complexity: situations with a limited number of diagnoses, options, data and risk to the patient. This could include services like postoperative pain treated with patient-controlled analgesia.

Moderate complexity: situations with multiple diagnoses, options and data from which to choose, with higher risk to the patient, like management of nonspecific low back and leg pain.

High complexity: situations with many diagnoses, options and data from which to choose, with unusually high risk to the patient. This could include treatment of cancer that has spread to other areas of the body.

The Table of Risk to help providers determine the most appropriate level of MDM to report also has been eliminated from the new guidelines. Instead, the proposed guidelines will include specialty-specific vignettes, or examples. These are expected to be similar to the clinical examples found in Appendix D of CPT 2000 and will describe typical encounters with typical patients.

What Happens Next?

Once the specialty-specific vignettes are complete, HCFA will work with physicians nationwide to pilot test two versions of the new guidelines. One version revises the original 1995 guidelines and uses a series of physical exam and MDM scenarios to help physicians and reviewers assign an appropriate level of service. The second version focuses more on how physicians make medical decisions and less on the history and physical exam. It reportedly involves little or no counting and includes MDM scenarios.

One major question for practices will be whether the reduction in number of levels (from five to three) will result in payment cuts, according to Carol Kolbinger, owner of the consulting firm Anesthesia Compliance Solutions in Rogers, Minn. Once HCFA releases the vignettes, it will be easier to make comparisons between the existing guidelines and the new ones based on
actual examples.

The success of these new guidelines lies strongly in the development of both types of vignettes, Prillaman agrees. These hopefully will give solid guidance so providers and coders may apply principles to assign appropriate codes.

HCFA hopes to have the new guidelines in place by January 2002. Until then, anesthesia providers and coders should continue to use either the 1995 or 1997
guidelines,whichever suits their practice better.