Urology Coding Alert

CMS's recently released 2018 proposed Medicare Physician Fee Schedule (MPFS) has caused quite a stir with their latest consideration to revise the 1995 and 1997 Evaluation and Management (E/M) Documentation Guidelines to "reduce clinical burden and improve documentation."

Read on to get the inside scoop – and how it could affect urology practices.

Why Should CMS Revise the E/M Guidelines?

According to stakeholders, both the 1995 and the 1997 E/M Documentation Guidelines are "administratively burdensome and outdated with respect to the practice of medicine," via the proposed MPFS. The reasoning behind this statement maintains that the guidelines are "too complex, ambiguous, and fail to distinguish meaningful differences among code levels."

In the 2018 proposed MPFS, CMS agrees with stakeholders and says there "may be unnecessary burden" with the E/M guidelines and they are "potentially outdated," especially in respect to the history and physical exam requirements.

In addition, since the E/M guidelines have not been revised regarding technology, specifically the increased use of electronic health records (EHRs), problems can arise for data and program integrity. Potential upcoding may also occur due to the frequently automated selection of code levels, according to the proposed MPFS.

Dig Into Possible E/M Comment Areas

CMS has opened its public comment period for issues it has introduced in the proposed MPFS. Take a look at the following proposed comment areas pertaining to E/M:

Area #1: CMS is debating if they should eliminate documentation requirements for the history and exam for all E/M visits at all levels.

CMS proposes this alternative - making MDM and/or time the dominant factor in determining the visit level.

"We believe medical decision-making and time are the more significant factors in distinguishing visit levels, and that the need for extended histories and exams is being replaced by population-based screening and intervention, at least for some specialties," according to the proposed MPFS.

In terms of using MDM as the dominant factor to determine visit levels, Michael Ferragamo MD, FACS, clinical assistant professor of urology, State University of New York, University Hospital and Medical School, Stony Brook, NY, offers the following example: The urologist sees an established patient for his six-month checkup for an enlarged prostate gland. The physician must take both a robust history and a robust exam. Then, his medical decision-making may look something like "I checked your PSA level, and you are doing great. Keep up with it. Here is your script for your Flomax. Here is a script for a urinalysis."

In this case, the decision-making may be quite limited, Hauptman says. With this proposal, the physician's level of care is called into question because the history and the exam he took does not count towards the level of service since it's just being based upon the decision-making.

If CMS decides to go this route, Hauptman recommends adding some of the history and exam elements into the medical decision-making.

Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, AAPC Fellow, AHIMA-approved ICD-10 CM/PCS trainer and president of Maggie Mac-Medical Practice Consulting in Clearwater, Florida, adds her thoughts about making MDM the dominant factor for determining service levels.

"I strongly believe there needs to be a history of present illness to support and to understand the level of medical decision-making," Mac says. "You cannot understand a medical decision-making level unless you have a history behind it."

Consider this example to emphasize Mac's point: A patient is seen because of a urinary tract infection. If the urologist solely documents that the patient has symptoms of a cystitis and doesn't elaborate further, the medical decision-making will probably be low. But, instead, the urologist elaborates whether or not the patient had chills and a fever, and documents that the symptoms had been present for several days. The patient has tried over-the-counter medicine with no relief of her symptoms. The patient had suprapubic tenderness and a urine culture was obtained.

The physician needs to mention all of this information to set the scene and to give a background about what's going on with the patient, Mac says.

"It's like going to a show on Broadway; you probably want to know what kind of show it is before you buy tickets," Mac adds. "You watch the show, you have this wonderful finale, and you either go away happy or not."

In this case, a patient will have a finale based on what her symptoms are, and how long she experiences them, according to Mac. You must gather this information.

Area #2: CMS wants to gain further insight into how changing the guidelines may impact physicians in different specialties, and how CMS will factor this impact into their decisions.

Area #3: CMS is contemplating if they should leave it up to individual physicians' discretion to what extent they should perform and document the history and physical exam.

Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh, doesn't agree with this method because she says physicians will not know what CMS is looking for. There should be a basis for which to gauge the patient's condition with the type of documentation to support the service being rendered.

When CMS says, "We are going to take money back," there needs to be reasoning behind why they are taking money back, Hauptman adds.

If it's left up to the physician, some physicians may just bill one level of service all the time, no matter what, Hauptman says. Or some may bill all high levels because their patients are specialized. Or some may bill just low levels because they don't know what CMS wants.

The current sets of guidelines do need to be revised, but not in such a drastic way, Hauptman continues. They can be changed to reflect the changes in technology, but keeping a core structure will help everyone in the long run.

Mac agrees that as far as the history, CMS should not leave it up to the physician's discretion.

The physician needs to do complete documentation of the HPI, Mac says. However, Mac does believe that CMS should leave it up to the physician's discretion whether or not he needs to document the ROS or the past family and social history.

Assigning points, perhaps, to the past, family and social history components, might help, Hauptman adds. A family history may truly not be necessary; however, a comprehensive social or past might. Physicians should be given the appropriate credit for the work that is being done to take care of a patient in the best way possible.

The exam should also be left to the physician's discretion, according to Mac.

The physician may have seen the patient a week ago or maybe he hasn't seen him for a year. The physician may need to do a complete exam. Or the patient's symptoms may have worsened, and the physician needs to perform a re-exam.

"I think it's up to the physician's discretion based on the patient's clinical background and history or when the patient was seen last, and what symptoms the patient presents with," Mac says.

Mac also voices her concerns about potential medical legal problems.

"Medical legal doesn't care what the physician billed," Mac says. "Did the patient have an exam for this problem, and the physician didn't write down the findings because it wasn't pertinent or it was negative? Therefore, the physician didn't do it, so the patient is going to sue because the physician should have performed and documented the exam element and the physician may be charged with a missed diagnosis as a result of not performing a 'standard of care' examination based on the presenting symptoms."

So, leave it up to the physician's discretion with the caveat that you need to be concerned with medical legal as well asthe levelof service, Mac recommends.

If you plan to submit a comment regarding one of the above E/M-related areas or another area that interests you, CMS will accept comments until 5 p.m. on Sept. 11, 2017. CMS plans to respond to these comments in its final rule.

In the meantime, you can read the proposed MPFS in its entirety here: https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-14639.pdf.