Gastroenterology Coding Alert

Just when many gastroenterologists had gotten accustomed to performing the more detailed examination requirements of the Health Care Financing Administrations (HCFA) 1997 evaluation and management (E/M) documentation guidelines, the agencys recently issued proposal for new guidelines indicates that a less restrictive examination system is being considered for adoption in January 2002. In the meantime, gastroenterologists should continue to follow either the 1997 or 1995 guidelines issued by HCFA and make sure that they are properly documenting the examination component of the E/M service.

In an attempt to distinguish between different levels of E/M service, HCFA issued E/M documentation guidelines in both 1995 and 1997 with the section on examinations being the main difference between the two. The 1995 guidelines allowed physicians to conduct either a general multisystem or single-system exam, and defined the levels of examination in a basic way.

There was no specific guidance, however, on what constituted the difference between the various levels of examination for coding and reimbursement, which caused concern among physicians. In the 1995 guidelines, an expanded problem-focused exam was defined as a limited examination of affected body systems, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J.

So to provide further guidance for physicians and to create specific audit criteria, HCFAs 1997 guidelines, while continuing to use the 1995 definitions for the various levels of examination, included the number of bullets (elements of examination) that must be performed and documented for each level. The 1997 guidelines also outlined the elements of the multisystem general examination and 10 single organ-system examinations (cardiovascular, ear/nose/throat, eye, genitourinary, hematologic/lymphatic/immunologic, musculoskeletal, neurological, psychiatric, respiratory and skin).

Although emphasis on bullet elements and counting added clarity to the 1997 guidelines, some specialists found it difficult to perform the required number of elements to qualify for upper-level E/M visits. The 1997 guidelines are clearly spelled out and easier to format into checklists, says Brink. For some specialties, following the 1997 guidelines can make it difficult for the physician to perform and document the required elements that constitute a level four and five E/M service. In cardiology, for example, it may be very difficult to perform and document all the elements needed for a comprehensive examination.

Because there was significant resistance to the new guidelines from physician groups, HCFA announced that physicians could choose to use either set of guidelines and that the agency would continue to develop a set of documentation standards that would meet with wider acceptance from the medical community. So for the past several years, physical examinations during E/M services could be measured by the following standards:

A problem-focused examination is defined in the 1995 guidelines as a limited examination of the affected body area or organ system. The 1997 guidelines state that this consists of performing and documenting one to five elements identified by a bullet.

This is a component of the following E/M codes: 99201 (new patient office visit), 99212 (established patient office visit), 99231 (subsequent hospital care), 99241 (office consultation), 99251 (initial inpatient consultation), 99261 (follow-up inpatient consultation), 99271 (confirmatory consultation) and 99281 (emergency department visit). It also can be a component of nursing facility and home visit E/M codes.

An expanded problem-focused examination as defined by the 1995 guidelines is a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). The 1997 guidelines state that this consists of performing and documenting at least six elements identified by a bullet.

It is a component of the following E/M codes: 99202 (new patient office visit), 99213 (established patient office visit), 99232 (subsequent hospital care), 99242 (office consultation), 99252 (initial inpatient consultation), 99262 (follow-up inpatient consultation), 99272 (confirmatory consultation) and 99282/99283 (emergency department visit). It also can be a component of nursing facility and home visit E/M codes.

A detailed examination as defined by the 1995 guidelines is an extended examination of the affected body area(s) and other symptomatic or related organ system(s). The 1997 guidelines stated this consists of performing and documenting at least two elements identified by a bullet from each of six areas/systems or at least 12 elements identified by a bullet in two or more areas/systems for the general multisystem exam.

It is a component of the following E/M codes: 99203 (new patient office visit), 99214 (established patient office visit), 99218 (initial observation care), 99221 (initial hospital care), 99233 (subsequent hospital care), 99234 (observation or inpatient care services), 99243 (office consultation), 99253 (initial inpatient consultation), 99263 (follow-up inpatient consultation), 99273 (confirmatory consultation) and 99284 (emergency department visit). It also can be a component of nursing facility and home visit E/M codes.

A comprehensive examination as defined by the 1995 guidelines is a complete general multisystem examination or an examination of a single organ system. The 1997 guidelines state that this consists of performing all elements identified by a bullet in at least nine organ systems or body areas and documenting at least two elements identified by a bullet from each of nine areas/systems for the general multisystem exam.

It is a component of the following E/M codes: 99204/99205 (new patient office visit), 99215 (established patient office visit), 99219/99220 (initial observation care), 99222/99223 (initial hospital care), 99235/99236 (observation or inpatient care services), 99244/99245 (office consultation), 99254/99255 (initial inpatient consultation), 99274/99275 (confirmatory consultation) and 99285 (emergency department visit). It also can be a component of nursing facility and home visit E/M codes.

New June 2000 Standards Proposed

On June 22, HCFA released its latest documentation proposal, referred to as June 2000. The proposal, which has a planned implementation date of January 2002, surprised many in the medical coding community because there was far less emphasis on counting elements than in the 1997 guidelines. The proposed levels of a multisystem examination are defined as follows:

A brief examination should include findings from one or two body areas or organ systems.

A detailed examination should include findings from three to eight body areas or organ systems.

A comprehensive examination should include findings from nine or more of the seven body areas or 13 organ systems, or at least three constitutional findings that are comparable to one body area or organ system.

For single system examinations, HCFA is creating specialty-specific vignettes that will guide physicians on what is considered appropriate documentation.

Three Tips for Better Exam Documentation

What the gastroenterologist does to document the examination will probably be the same for both the 1997 and the June 2000 guidelines, according to Martin Gottlieb, president of Martin Gottlieb & Associates Inc., a medical billing company in Jacksonville, Fla. What the gastroenterologist documents will remain the same, he says. The new guidelines look like they will require fewer elements for an examination, and gastroenterologists may be able to bill a higher level of service than under the 1997 standards.

The following three tips on documenting examinations will apply to whatever set of standards (1995, 1997 and June 2000) are in effect:

1. Checklists and templates make documentation easier. It takes longer to write everything down than to do the exam, claims Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a member of the American Medical Associations CPT Advisory Panel. Thats why I have a template for exams, where I can quickly check off all of the normal or negative elements.

Brink agrees that a checklist can help. HCFA has said that it is okay to check off when an element is normal; you dont have to write it all down, she explains.

2. Documenting patient history helps justify exam. Brink cautions gastroenterologists who skimp on the history portion of the E/M service with an established patient and focus solely on the exam portion. A gastroenterologist only needs to document two out of three components (history, examination and medical decision-making) for an established patient visit, she says. But the information obtained by the gastroenterologist in the history, history of present illness (HPI) or interval history is what necessitates performing the examination. If theres no history, HPI or interval history documented, where is the medical necessity to perform the exam?

Brink suggests that gastroenterologists always write down the chief complaint or reason for the visit with every E/M service. Since most gastroenterologists also review the patients original medical history form during the course of the visit, she advises them to document in the patients medical record that the form was re-reviewed, and note the date of the original history form, as well as any changes to the original history.

3. Abnormal findings must be explained. Although HCFA has stated that a brief notation indicating negative or normal is enough to document normal findings, a notation of abnormal is not sufficient. If theres an abnormal finding during the examination, it is not enough just to write the word abnormal in the patients record, explains Brink. You have to include a statement such as abdomen is tender or mass in abdomen.

Copies of the 1995, 1997 and proposed June 2000 E/M documentation guidelines can be downloaded from HCFAs Web site at www.hcfa.gov/audience/planprov.htm.

An analysis of the proposed June 2000 E/M documentation guidelines can be downloaded from the Martin Gottlieb & Associates Web site at
www.gottlieb.com/documentation.htm.

Continue Coding for Existing Guidelines

The June 2000 guidelines would require a change in the definition of E/M service codes, which are currently based on four levels of examination. In addition, HCFA will be spending the next year testing its June 2000 guidelines and making revisions, which leads some in the medical coding community to believe that significant changes still may be made to the proposal.

Until a new set of guidelines has been adopted, physicians need to use the 1995 or 1997 guidelines. I now hear that some medical practices are putting off having their physicians trained in E/M documentation until they find out whether the June 2000 guidelines are going to be adopted, says Gottlieb. Those practices could be committing fraud for close to two years if they arent committed to the 1995 or 1997 standards. They shouldnt be putting off training; they should be learning the old stuff.

The consensus among coding experts seems to be that the general multisystem exam described in the 1997 guidelines is what most gastroenterologists are or should be using in their practices. I use the multisystem exam outlined in the 1997 guidelines because Im not quite sure what the definition of a detailed or comprehensive exam is under the 1995 guidelines, says Weinstein.

Because digestive diseases are often linked to other organ systems, its not hard for a gastroenterologist to do a detailed or comprehensive exam under the 1997 guidelines. (See insert for general multisystem examination.)

It probably takes four or five minutes to do a 12-element detailed exam, Weinstein estimates. I check the patients vital signs, inspect the mouth for lesions and look at the neck for lymph nodes and for signs of thyroid disease. I examine the lungs and listen to the heart for murmurs, especially if Im planning to sedate the patient in the future for a procedure. I listen for bowel sounds and perform a thorough abdominal exam. I document these examination elements and also note the patients mental status.

Weinstein emphasizes that these elements are all part of his normal exam routine, and that the HCFA guidelines are not requiring him to do anything differently. The 1997 guidelines are not a constraint on me, he claims. Its doing the documentation that is the hard part. A comprehensive examination will take a little more time, and documentation is a bit more tedious.