July 2000 AAOS Report

HCFA unveils new documentation guidelines

The Health Care Financing Administration (HCFA) unveiled a new draft version of evaluation and management (E/M) documentation guidelines at a public meeting on June 22. HCFA believes that the new version will be clearer and less ambiguous than either the 1997 documentation guidelines or the 1999 proposal by the AMA CPT Editorial Panel. The new guidelines will include specialty-specific vignettes for physicians to use as a guide in selecting the appropriate level of service for the physical examination and medical decision-making sections. The physical exam will be simplified from four to three levels of service based on the number of body systems or organs examined. Bulleted lists of required elements will be eliminated altogether. The documentation of the patient history remains largely unchanged from previous versions. HCFA plans to run two extensive pilot tests before the guidelines are implemented. The first test will give equal weight to the history, physical exam and medical decision making components, as do the current guidelines. The second pilot project will focus on medical decision-making as the key component in selecting a level of E/M service. Further details on the pilot studies were not available at the meeting. HCFA hopes to implement the new guidelines in January 2002. In the meantime, physicians are advised to continue to use either the 1995 or 1997 version, whichever is more advantageous.


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