Coping with the new AMA/HCFA documentation requirements
By Caral Edelberg
President
Medical Management Resources
Emergency physicians throughout the United States are beginning to familiarize themselves with the new AMA/HCFA documentation guidelines slated to go into effect no later than December 31, 1998, following a three-month educational grace period. Establishing new, objective requirements for the physical examination, they demand extreme compliance. If they are not followed, sanctions may result in significant loss of revenue. (Current projections indicate a potential loss of revenue in the emergency practice might exceed 20%.) Although the American College of Emergency Physicians (ACEP) and other medical specialty societies continue to request a delay in implementation, none has been granted.. Talks continue in hopes that revisions to these guidelines will make them more "emergency-medicine" friendly. In their current format, they are cumbersome at best when applied to the myriad treatment scenarios common in the ED.
HCFA has no plans to provide educational materials or guidance for transition to these complex guidelines. They have, instead, looked to the medical specialty societies, like ACEP, to provide the necessary educational assistance. Therefore, the guidelines in their entirety are a must-read for every practicing physician. Although implementation for Medicare has been mandated by HCFA by January 1, 1998, adherence to the new guidelines may be required by other payers, though the AMA currently must wait until at least 1999 to publish the guidelines in CPT.
Revisions in types of physical examinations
These guidelines dramatically revise the documentation requirements for the physical examination, differentiating between two possible exam types and contents; the general multi-system examination (one template) and the single organ system examination (10 templates). The type and content of the examination selected by the examining physician should be based on clinical judgment, patient history, and the nature of the presenting problem. This would indicate that the examining physician has the full responsibility for determining which of the 11 templates most closely fit the content of the examination. However, due to the onerous requirements for many of the examinations and their questionable fit for emergency medicine, it may not be this simple. It is conceivable that the template that most closely fits the type of examination performed may not fully apply to the specific body area/system affected. For example, the required elements of the hematologic/ lymphatic/immunologic examination more closely match the core content of most comprehensive emergency medicine examinations. Although HCFA indicates that the type of exam is the choice of the examining physician, there is no assurance, at this time, that the template selected by the physician will be the one used by a HCFA examiner during future audits.
The single organ system templates include specific examination criteria for each of the following body areas/systems:
• cardiovascular
• musculoskeletal
• ears, nose, mouth and throat
• neurological
• eyes
• psychiatric
• genitourinary (male and female)
• respiratory
• hematologic/Lymphatic/Immunologic
• skin
The general multi-system examination includes specific examination criteria for all of the following body areas/systems:
• constitutional
• gastrointestinal (abdomen)
• eyes
• genitourinary(male or female)
• ears, nose, mouth, and throat
• lymphatic
• neck
• musculoskeletal
• respiratory
• skin
• cardiovascular
• neurologic
• chest (breasts)
• psychiatric
The level of examination performed will determine the level of the physical examination portion of the CPT emergency department evaluation and managemaent (E/M) codes. The overall physical examination level will depend upon the content documented and identified as "elements" or "bullets". Each level of the physical examination must contain the number of elements (bullets) required to qualify for the selected level of E/M code. Each of the 11 templates defines the content of each of 14 body area/system examinations. As such, they provide a higher level of objectivity in assigning an E/M level.
Differentiate performance from documentation
In the templates, certain body area/organ system exams are enclosed in a box with a shaded border. For the comprehensive examination, performance of all elements identified by a bullet (whether in a shaded or unshaded box) on the chosen template is required; However, documentation is only required for every element in a box with a shaded border and at least one element in a box with an unshaded border. One of the more controversial aspects of these new physicial examination criteria is the conflict between these documentation and performance requirements. (In the past, only the services that were documented could be considered to have been performed.)
To illustrate the difference at two levels, in the musculoskeletal exam template, the unshaded box for the cardiovascular examination contains the following single-bulleted element: "examination of peripheral vascular system by observation (e.g., swelling, varicosities) and palpation (e.g., pulses, temperature, edema, tenderness)." The cardiovascular exam is required for the comprehensive muscuskeletal exam. For a physician to include it, both the observation and palpation must be performed, although either the observation or the palpation would be required for documentation.
In another example, the respiratory exam template contains two bulleted elements in the neurological/psychiatric system/body area: "Brief assessment of mental status including: orientation to time, place and person; and mood and affect (eg, depresion, anxiety, agitation.) Both elements would be required performance for the comprehensive exam, but only one would be required to be documented. However, without detailed documentation, no evidence would exist to indicate that both bullets were performed.
The larger issue of performance vs. documentation is ensuring that, although it was not documentated, the service was performed. Coders reviewing charts have no indication and assurance that a service was performed, unless it was documented. This may place the physician at risk if these assumptions are made. Without such assurance, physicians are at high risk for fraud and abuse allegations as they bear the ultimate responsiblity for all billing performed in their names. How can a physician ensure that the coder is performing the appropriate selection when documentation is incomplete? Certainly these new guidelines will require communication between coder and physician to set the limits of interpretation made by the coder when the physician documents less than the required amount of information.
As a result of these and similar issues, emergency physicians have gravitated toward the general multi-system examinations for the content for their examinations. The general multi-system exam does not differentiate shaded and unshaded boxes but does require the examination of a greater number of body systems/areas for the comprehensive examination (two elements from at least nine body areas/systems.(See supplement enclosed in this issue.)
The level of examination is determined from a review of the content of each of the templates and the number of elements or "bullets" identified. Table 1 illustrates the content requirements for each level of exam for each of the exam types:
To further illustrate the extent of the menu for each exam, Table 2 shows the number of bullets in each of the exam templates.
Considerations for the ED coder
For emergency medicine coders, a higher degree of understanding of medical terminology will be required to translate current medical record documentation terms into the terms defining content within each template. In addition, guidance provided by the AMA and HCFA indicates that, although the physician may not provide all documentation as illustrated for each element of a selected physical examination, the coder may select that element for consideration if it is known that the physician actually provided the service. This is guaranteed to increase both confusion and liability as coders attempt to differentiate between documentation and performance.
It is essential that all physicians become familiar with the various templates and their rules for use in supporting the emergency department E/M code levels. Although initially problematic, an understanding and working knowledge of when and how to apply these guidelines will assure that all medical records are documented appropriately. There is little question that, due to their objective nature, the templates will be used by Medicare examiners for assessment of documentation to support selected E/M levels. Physician dictation, now almost essential, should follow an outline of the essential components for each type of exam. If records are written, physicians should allocate more time to complete the physican exam notations and begin the process of identifying additional space to write.
Coders should begin orientation to the templates and, more specifically, the terms contained in each that may be unfamiliar. Dialogue with emergency physicians in the practice should include practical definitions and content of the examinations to support terms not commonly used. Coders should not "assume" and/or translate illegible or unknown terms without first consulting the treating physician or a medical dictionary.
All emergency physicians and coders should continue to monitor Medicare communications and bulletins generated by ACEP as discussions about possible revisions continue. If questions arise that can not be answered by a thorough review of the documentation guidelines in their entirety, the local Medicare carrier should be consulted.
[Editor's note: For a chart detailing the elements of the general multi-system specialty examination, please see the supplement enclosed in this issue.]
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