Orthopedic Coding Alert

In orthopedic care, as in other disciplines, two schools of thought exist when it comes to evaluation and management (E/M) guidelines. Some physicians and coders swear by the 1995 Health Care Financing Administration (HCFA) guidelines for assessing the correct level of E/M service, while others see the 1997 guidelines as not only a more precise tool, but also the wave of the future for E/M coding.

An E/M History Lesson

CPT first introduced the system of coding office visits, known as E/M codes, in 1995. Prior to that, office visits were called low, moderate, intermediate and high, with very little definition to distinguish between levels. The 1995 E/M codes were an attempt to define the intensity of medical service delivered while maintaining some flexibility to accommodate the natural variations found in medical practice.

Although the HCFA saw the 1995 system as an improvement over the prior rules, HCFA thought the E/M definitions were still too vague to allow Medicare auditors to pinpoint the correct level of service to be assigned to the documentation. The 1995 guidelines instructed physicians to conduct a complete single system or a complete multisystem exam, but gave little guidance regarding what constituted a complete exam. When an orthopedist chose to do a comprehensive musculoskeletal examination, for instance, there was no tool to measure when he or she reached the comprehensive level.

With input from HCFA, the CPT committee created the 1997 E/M system, which intended to replace the ambiguity of the 1995 system with a very specific list of bullet items in history, exam and medical decision-making that must be performed and documented to justify a specific level of service.

The new system requires the physician to document everything and tries to make the examination criteria for one discipline comparable to other disciplines to set more universal criteria. This makes it easier for auditors to assess the level of work that was done.

Thomas Kent, CMM, principal of Kent Medical Management, a practice management and consulting business based in Dunkirk, Md., says that HCFA thought the 1997 guidelines were an improvement over 1995s. The 1997 system made it very difficult for physicians to reach the level five service (99205 or 99215, office or other outpatient visit for the evaluation and management of a new (99205)/established (99215) patient), says Kent, and made auditing more precise. But physicians using the 1995 system hated the 1997 system and considered it too complex to utilize on a daily basis, and too inflexible. Both systems are in use today. Kent explains that if audited, HCFA will use the system that is to the advantage of the physician.

Multispecialty vs. Specialty System

According to Lynda Munsey, CPC, coding analyst for the University of Florida at Jacksonville/Physicians Inc., resistance [...]