ED Coding and Reimbursement Alert

As though managing the issues associated with ambulatory payment classifications (APC) werent enough to keep us busy, the Health Care Financing Administration (HCFA) released a draft of its retooled documentation guidelines (DGs) in June. HCFA promises significant work to come as these newest attempts at nationally standardized guidelines maneuver through a validation process for a target release by 2002.

Although HCFA and the American Medical Association (AMA) are expected to continue expanding the supporting information for these guidelines, the elements published in this draft will help coders and physicians begin to develop coding and documentation policies to ensure compliance once the draft guidelines are released.

HCFA has applied significant resources to bringing this new draft to providers for consideration due, in no small part, to shared concerns voiced by practicing physicians that the 1997 and proposed 1999 guidelines were inappropriate. In addition, HCFA was concerned that the draft guidelines encouraged physicians to perform unnecessary services or document irrelevant information to bill a higher level of service.

Following significant internal review and technical assessments, HCFA identified significant variations in interpretations of the guideline components among physician and nonphysician reviewers to the extent that nonphysician reviewers assigned a lower level of service when using the 1997 DGs, and physician reviewers assigned a higher level of service when using the proposed 1999 DGs. The variations in the assigned service levels increased when physician reviewers used the proposed 1999 DGs because of the differences in reviewers evaluation of the medical decision-making component.

HCFAs data on physician outlier claims, determined through its review and comparison of the 1995 and 1997 documentation guidelines, indicates that more than 95 percent of outlier claims were either denied or assigned a lower level of service no matter which version was used to score the evaluation and management (E/M) level. About 40 percent were denied altogether, and approximately 57 percent were assigned a lower level of service.

Interestingly, in the outlier review, more claims were assigned two levels of service lower with the 1997 E/M guidelines. Through its technical evaluation, HCFA determined that the 1995 documentation guidelines result in more consistent, reliable medical review.

To limit the confusion, HCFA concluded that it would need to carefully evaluate any documentation guidelines to improve the interpretation of medical decision-making. The 1997 draft guidelines and proposed 1999 guidelines provided unacceptable incentives to perform unnecessary services and generated confusion through the table of medical decision-making. That table was deemed too rigid and the list of examples too irrelevant or incorrect to apply to most E/M services.

In essence, the score sheets that required counting and review of multiple tables created the wrong incentives and deviated from the established CPT definitions, a serious issue with the AMA throughout the reconstruction process for the proposed 1999 guidelines.

HCFAs current goal with the draft June 2000 documentation guidelines is to find an alternative to counting elements to correctly score each E/M level. To do this, HCFA wanted to develop a system that will track the CPT definitions while emphasizing documentation of clinically relevant care and minimizing the use of rigid, potentially irrelevant tables. Some of the more noteworthy items included in these draft guidelines are:

Similarity to the 1995 documentation guidelines, which seem to be the preferred choice of most emergency medicine groups, via referencing the same key components.
Future development of supplemental specialty-specific vignettes for physical examinations and medical decision-making, a much-needed clarification because emergency medicine didnt seem to fit into past versions.

Modifications to the key elements (history, physical examination and medical decision-making) include:

1. History requirements similar to the 1995 guidelines with the following exceptions:
ROS organ systems (brief, 1 or 2; extended, 3 to 8;
complete, 9-plus) notations negative must be related to specific organ systems, not a general statement relating to the entire ROS (ROS negative).
PFSH B pertinent (1 of 3)/complete (2 of 3)
2. Physical exam: three levels, specialty-specific vignettes to be developed.
No more bullets.
No required elements.
Minimal counting (three constitutional one organ system).
Single and multisystem exams.
Brief 1 or 2 organ systems or body areas.
Detailed 3 to 8 organ system or body areas.
Comprehensive 9-plus organ systems or body areas (body areas would qualify for a 99285).
3. Medical decision-making: The MDM reference table would be greatly simplified to reflect the severity/urgency of illness, differential diagnosis/data review, and treatment plan.
Three levels low, moderate, and high.
Two of three must meet or exceed the requirements for the type of MDM to qualify.
No more list of problems, tests, or procedures.
Specialty-specific vignettes in development for physicians/coders to reference to help differentiate
levels of physical examination and MDM.

HCFA plans to continue to study the complexities and practical application of these draft guidelines as it develops physician and reviewer training programs. Vignette development, expected to start immediately, may use actual medical records rather than hypothetical examples, which is considered to be a significant benefit in developing practical applications of these guidelines in the real world.

HCFA does, however, plan to use a standardized score sheet for medical reviewers to use during the validation studies. HCFA continues to instruct Medicare contractors to use the 1995 and 1997 documentation guidelines for claims review, the choice between the two decided by which is more favorable to the physician.

What can emergency department physicians and coders do, in the interim, to improve documentation and begin construction of coding templates to begin to phase in these new guidelines as they move through the development process? Most of the work will remain with the physicians and their method of documentation until we get closer to the final product and know how the coding score sheets will work.

Physicians should continue to focus their documentation efforts on the details of the care rendered, particularly as it relates to the requirements of the 1995 documentation guidelines, which seem to be the dominant format used by HCFA in developing the draft June 2000 guidelines.

Most emergency physicians have vastly improved their documentation, and the industry now has numerous templated and electronic solutions to their dictation and documentation needs. Coders, however, should remain consistent in providing feedback to those physicians who routinely omit significant components in documentation of the care they render. Special emphasis should be given to the elements of medical decision-making that provide the foundation and justification of the services that are provided in the emergency department.

Although the documentation guidelines are specifically focused on professional coding, it is clear that the implementation of the OPPS/APC payment methodology for hospitals this August will put considerable focus on documentation provided by physicians, midlevel providers, and nurses to facilitate the identification of all identifiable services for APC payment.

Hospitals, now more than ever, must focus on physician documentation that will play a major part in driving their reimbursement, not just the reimbursement to the physicians. Procedures must be clearly documented consistent with CPT/HCPCS definitions. Thus, coders must continue to work with emergency physicians and medical staff to assure that the procedures performed in the emergency department are clearly documented in detail to facilitate selection of the correct procedure code for billing both the physician and facility service.
For continuing updates on the evolution of the draft June 2000 documentation guidelines and a copy of the guidelines in their entirety, monitor HCFAs Web site at www.hcfa.gov.