August 1999 Bulletin

Proposed E/M guidelines favor menu of examinations

HCFA studies recommendations, pilot tests expected

The American Medical Association's recommendations on revisions to documentation guidelines for Evaluation and Management (E/M) services, which were submitted to the Health Care Financing Administration in June, include the elimination of the single system examinations in favor of a "menu" of approximately 264 exam items organized by body system.

Physicians would be able to choose exam items from any body area (e.g., musculoskeletal, neurologic, cardiovascular) in order to reach the appropriate level of service.

In June 1998, the AMA House of Delegates had passed a resolution opposing any use of numerical standards; however, HCFA said some degree of counting would be necessary. Therefore, although the AMA recommendations attempt to de-emphasize counting, it has not been eliminated. Like the 1997 guidelines, physicians will need to document 18 exam items to bill a comprehensive exam, 12 for a detailed exam, and six for an expanded problem-focused exam.

The AMA recommendations also streamline and simplify the history and medical decision-making sections of the guidelines. Overall, the recommendations emphasize that "the medical record should be first and foremost a tool of clinical care and communication."

The previous version of the E/M documentation guidelines was published by HCFA and the AMA in 1997. The guidelines focused on the three key components of an E/M service: history, physical examination and medical decision-making. After their publication, physicians across the country complained about the complexity of the guidelines and the significant amount of documentation required. Due to this outcry, HCFA agreed to delay implementation of the guidelines and asked the AMA CPT Editorial Panel for guidance in making revisions.

HCFA has not stated when it will review the AMA's recommendations and publish its final decision on the guidelines. The agency has agreed to conduct pilot tests of the guidelines before they are implemented, but no details on the pilot had been made available at press time. It is unlikely that the documentation guidelines will be implemented before mid-2000. Until that time, physicians are advised to follow either the 1995 or 1997 versions of the guidelines.

The entire text of the CPT Editorial Panel recommendations are available on the AMA web site in the "E&M" section.

Laura Nuechterlein is senior policy analyst, department of health policy, American Association of Orthopaedic Surgeons.

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