Primary Care Coding Alert

The Health Care Financing Administration (HCFA) unveiled proposed documentation guidelines (DGs) for physician evaluation and management (E/M) services this summer during a town hall meeting at its headquarters in Baltimore.

The June 2000 DGs are based on the 1995 version, a move heralded by family physicians and coders. HCFA had developed 1997 E/M guidelines intended to replace the 1995 version, but those were viewed as overly complex, requiring more documentation than clinically necessary. The June 2000 proposed DGs also replace a draft that was circulated in 1999.

We appreciate HCFAs return to the 1995 guidelines as a starting point for any new documentation guidelines, Lanny Copeland, MD, board chair for the American Academy of Family Physicians (AAFP), wrote in a letter to HCFA. In our experience, family physicians were more comfortable with the 1995 documentation guidelines, especially the examination portion, which emphasized a multisystem approach that is consistent with family practice. Although not perfect, the 1995 documentation guidelines did have much to commend them relative to the 1997 documentation guidelines and the proposed 1999 documentation guidelines. Indeed, we described the 1997 documentation guidelines as too flawed to be fixed.

According to HCFA, the June 2000 DGs are designed to reduce the volume of regulations and complex requirements that have baffled physicians and coders alike. They eliminate all references to shaded systems and bullets, and reduce element-counting hallmarks of the 1997 version. In addition, the new system will feature specialty-specific vignettes to help physicians and coders assign appropriate service codes.

After pilot testing, modifications and a physician education phase, the final version of the June 2000 DGs is expected to take effect in early 2002.

June 2000 Draft Represents a Mixed Bag

We believe our new, simpler guidelines will provide clear and unambiguous guidance and streamline the documentation required for clinically appropriate record keeping and verification that services were medically necessary and rendered as billed, says Nancy Ann DeParle, HCFA administrator. HCFA officials also stressed that clinical care, not documentation, should be a physicians primary focus, and that the new draft guidelines are designed to support this.

Kent Moore, manager of healthcare financing and delivery systems for the AAFP, notes that although many of the proposed DGs would simplify family practice coding, other modifications may be disadvantageous.

Evaluating the proposal in the context of the three primary areas of emphasis for family practice E/M visits physical examination, history and medical decision-making Moore points out some pluses and minuses. I would rate the changes in the examination portion as a plus and the changes in the history section a minus. The modifications to the medical decision-making (MDM) portion are still a big question mark.

Physical Examination Components

The key benefit to the June 2000 DGs for physical examination, Moore explains, is that the general approach reverts to the 1995 guidelines. Back then, documentation for various levels of exam was based on the number of organ systems or body areas examined.

That was a workable approach for many family physicians, but it proved problematic for specialists who focus on a single system (e.g., endocrinologists), Moore continues. It became hard for them to document a level-five exam, for instance, because the higher levels of service were defined by multiple systems reviewed. The 1997 version tried to compensate for this by adding complex bullet points and shaded boxes.

The June 2000 DGs will rely on the number of organ systems examined to determine exam levels and will add clinical vignettes to assist specialists in determining how to code single-organ system exams. These vignettes will be developed in upcoming months with input from family practice and other specialty physicians.

This is a very positive change, agrees Mary Jean Sage, CMA-AC, president of The Sage Associates, a practice management firm based in California. Family physicians focus on the whole patient and review four or five systems on a regular basis. The return to the simpler guidelines is good news.

History Components

Although HCFA has indicated that the objective of the June 2000 DGs is simplification, the modifications require additional documentation in the history portion of the guidelines, specifically for the review of systems (ROS) and past family and/or social history (PFSH).

Moore notes that the proposed guidelines for an extended ROS are slightly more stringent. In the 1995 DGs, a review of two to nine systems described an extended service. The June 2000 draft requires three to eight systems. At the same time, documentation for a complete ROS is slightly less restrictive.

Level of ROS 1995 DGs June 2000 DGs

Brief 1 organ system 1-2 organ systems
Extended 2-9 3-8
Complete 10+ 9+

In addition, Moore says the draft DGs for PFSH have added requirements. In the past, there were no PFSH requirements for an expanded history, although only one comment on past family or social history was required for a detailed history. In the latest version, however, one comment is required for an expanded history and two or three are required for a detailed history, depending on whether the patient is new or established.

On the other hand, Sage points out a positive change in the history of present illness (HPI) component. These guidelines add language about patients who are seen for medication management, she says. This will help coders and others reviewing the documentation to determine the level of visit.

The new guidelines list elements that may be reviewed during the HPI, including how well the patient is com-plying with the treatment plan, the effectiveness of the medication, side effects experienced, and verification of dose and frequency.

Many family physicians do follow-up care on patients taking multiple medications to manage hypertension, heart conditions, etc., and they probably already document this quite thoroughly, Sage says. The language in the draft DGs may help those who review the records more easily to classify an HPI as extended or comprehensive.

Medical Decision-making Components

Another significant change in the June 2000 DGs is a simplification of MDM. Current E/M guidelines recognize four levels of medical decision-making: straightforward, low, moderate and high. The most recent version reduces this category to three levels: low, moderate and high.

Although on the surface these changes appear to be a step in the right direction, Moore notes that much of the language in this section of the proposal is confusing. HCFA will need to clarify some of its expectations in areas of assessment and treatment planning, for instance, he says. It also appears that the MDM guidelines dont account for the number of diagnoses involved in each encounter, although this has been the accepted standard in the past and appears in the CPT definitions.

I can see where it would be problematic for those reviewing the records to understand how to apply the guidelines. They are very subjective, Sage asserts. She adds, This subjectivity also could work in a coders favor. If a practice undergoes a review in areas that are subjective, there is more room for the practice to argue its case for a higher level of service coding.

As with the physical examination portion of the June 2000 DGs, MDM guidelines will be cross-referenced to specialty-specific vignettes to help physicians determine appropriate levels of medical decision-making. Family physicians should be very interested in watching how these develop because they will influence how physicians determine the level of E/M service, Moore says.

General Concerns

As family physicians review the details of the June 2000 draft, Moore says they should note that some of HCFAs proposals are not consistent with CPT descriptions and requirements. These deviations are of concern, and they are areas that should be addressed with HCFA, he says. One example is the change in PFSH documentation requirements for an expanded problem-focused history.

In addition, Moore says the draft seems to indicate that HCFA is moving toward reducing the number of E/M service levels. There is nothing explicit, but it seems that HCFA is heading toward a reduction in levels of service from the current five, down to three or four. He adds that indicators include the changes in the medical decision-making component of the guidelines, as well as comments HCFA has made in summary documents noting its support of efforts to revisit the current CPT structure and descriptors.

HCFAs Next Step

The next step, according to HCFAs plans, is to develop the clinical vignettes that will define the physical exam and medical decision-making components better. HCFA will award a contract to an outside entity to develop the vignettes. What process that contractor will use is unknown, but it is anticipated that it will involve input from the medical specialty societies.

Many coding professionals are skeptical about how effective the vignettes might be. To some, it appears to be a real can of worms, Sage says. Its hard to imagine that HCFA can develop enough vignettes to apply to all the different scenarios that arise in various specialties.

Following vignette development, HCFA has proposed two studies of the draft DGs before they are finalized, according to DeParle. The first study is designed to assign equal weight to each key component medical decision-making, history and physical examination. The second version will place a higher value on medical decision-making and rely less on history and physical examination. Each study is expected to take six months.

Moore says that the AAFP is concerned about the second study, noting that de-emphasizing the importance of history and exam reduces the importance of interaction with patients. In addition, appropriate medical decision-making depends a great deal on exam and history it cant be done without them.

It will be crucial for HCFA to include a broad range of specialties and geographic areas in the studies, Sage adds. Family physicians in Florida and Arizona treat a very different patient population than those in Montana and Wyoming, for instance. It will be challenging to develop a study that is comprehensive.