New E/M Guidelines Designed To Simplify Documentation
Published on Sun Oct 01, 2000
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 [...]
