August 2000 Bulletin

HCFA shows draft E/M guides

Specialty societies to develop vignettes; pilot testing planned

By Laura Nuechterlein

The Health Care Financing Administration (HCFA) has unveiled a new draft version of the evaluation and management (E/M) documentation guidelines. The agency plans to conduct extensive pilot tests on the guidelines and hopes to have them in place by January 2002. These new guidelines will then replace the 1995 and 1997 versions currently in effect.


HCFA originally developed E/M documentation guidelines because of its concerns that the CPT code definitions were insufficient to ensure correct coding by physicians, or consistent and reliable review by carriers. Guidelines were developed which outlined the documentation requirements for the three "key components" of all E/M services: patient history, physical examination and medical decision-making.

The initial draft, developed with the assistance of the American Medical Association, was implemented in 1995. Many specialists, including orthopaedic surgeons, criticized this version, because there were no clear requirements for a complete single-organ system physical examination. As a result, some Medicare carriers would not allow certain specialists to bill for high level (level 4 or 5) office visits.

In response, HCFA and the AMA, with cooperation from specialty societies, developed revisions to the documentation guidelines that included 10 single system exams (including a musculoskeletal exam). After the revised guidelines were published in late 1997, there was a firestorm of protest from physicians across the country. Widespread objections were raised regarding the lengthy and complicated lists of elements required to document both the physical exam and the medical decision-making. Physicians felt that the guidelines were so onerous that more time would be spent documenting each visit than actually providing patient care.

The protest culminated in a resolution passed at the June 1998 AMA House of Delegates meeting opposing "any documentation system that requires quantitative formulas or assigns numeric values to elements" in the medical record. Because documentation of E/M services was scrutinized closely as part of HCFA’s anti-fraud and abuse efforts, physicians insisted that any guidelines must be more clinically relevant and simpler to follow. Under heavy pressure, HCFA decided to revise the guidelines again. The AMA CPT Editorial Panel agreed to provide technical advice to these efforts, and forwarded recommendations on the E/M guidelines to HCFA in mid-1999. HCFA officials revealed the results of its work at a public meeting on June 22, 2000.

June 2000 draft

The California Medical Association had previously requested that HCFA minimize documentation requirements altogether and instead focus on peer review of outliers. However, HCFA officials claim that their initial assessment demonstrates that some degree of documentation guidelines is necessary for physicians and reviewers. HCFA medical officers believed both the 1997 guidelines and the 1999 AMA proposal were too complex and ambiguous, so they based the new draft on the original 1995 guidelines. In the new draft, the patient history portion has not changed substantially from previous versions. Documentation requirements will continue to focus on the chief complaint, history of present illness (HPI), review of systems (ROS), and past, family and social history (PFSH). The HPI will include a more explicit recognition of medication monitoring. The ROS and/or PFSH may be recorded by ancillary staff, or on a form completed by the patient. The physician must then make a notation supplementing or confirming the information recorded by others.

The most significant change to the guidelines is found in the physical examination section. The physical exam has been simplified from four levels of service (problem focused, expanded problem focused, detailed, and comprehensive) to three (brief, detailed, comprehensive). For purposes of documentation, the following body areas and organ systems will be recognized:

Body areas

Organ systems

In addition, a description of a minimum of three constitutional findings (e.g., vital signs, general appearance) is equivalent to one body area or organ system.

Most importantly, the bulleted lists of specific elements required for each body/organ system exam have been eliminated completely. A general multi-system exam requires documentation of relevant findings from:

For the brief, detailed, and comprehensive single system exams, specialty specific vignettes will be developed for each level of service.

The medical decision-making component has also been simplified from four levels of service to three. Documentation must still include indications of the severity/urgency of the problems and risk of complications, the differential diagnoses and amount and complexity of data reviewed, and the treatment plan (including diagnostic and therapeutic tests, procedures, and interventions). Under the 1997 guidelines, physicians must study several charts in order to determine the appropriate level of service; as in the physical exam section, under the new guidelines these charts have been replaced by specialty specific vignettes.

Next steps

The success of the new guidelines in simplifying the documentation process will depend heavily on the vignettes for the physical exam and medical decision-making components. HCFA has stated that it will work with the national medical specialty societies to develop vignettes for all levels of service, consisting of conditions commonly encountered by physicians in a wide variety of specialties. However, no additional details on the process or time- table were made available. Once these details have been clarified, the CPT and ICD Coding Committee will participate in this process on behalf of the AAOS.

After the vignettes have been finalized, HCFA will conduct two separate pilot tests of the guidelines. The first 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. Again, no further details on either pilot test were made available, including the issue of how many volunteer physicians will be required or how they will be recruited. HCFA also promises to conduct extensive education programs for both physicians and medical reviewers.

The Practicing Physicians Advisory Council will devote its Sept. 11, 2000 meeting to a review of the draft E/M documentation guidelines. National medical specialty societies, including the AAOS, are in the midst of analyzing the new guidelines and developing comments to HCFA. All physicians are encouraged to forward comments on the new guidelines and the proposed pilot studies to the following address: Terrence Kay, Director, Division of Practitioner and Ambulatory Care, PPG/CHPP, C4-02-06, 7500 Security Blvd., Baltimore, Md. 21244.

HCFA hopes to implement the new documentation guidelines in January 2002. Until that time, physicians are advised to continue to use either the 1995 or 1997 version, whichever is more advantageous. For more information or a copy of the new draft guidelines, contact Laura Nuechterlein, senior policy analyst in the AAOS department of health policy (847) 384-4328.

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