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 [...]