HCFA’s E/M Documentation Guidelines: 1995-2000
By Michelle A. Green, MPS, RHIA, CMA, CTR
Professor
Alfred (NY) State College
When the Resource-Based Relative Value Scale system (RBRVS) was implemented in 1992, the Health Care Financing Administration (HCFA) requested that the American Medical Association in Chicago revise the common procedure terminology (CPT) visit codes for office and hospital services. The American Medical Association revised the codes and created evaluation and managment (E/M) services. HCFA then released E/M Documentation Guidelines so that Medicare could be certain it was paying for correct levels of service. The guidelines implemented in 1994 are referred to as the 1995 Documentation Guidelines (DG), but they were criticized because requirements for a complete single system examination were unclear. Because medical reviewers rarely gave credit for complete single system exams, specialists were not able to meet the documentation requirements for higher level E/M services. In addition, it was difficult to ensure work equivalency between multi- and single-system exams.
In response, an alternative set of DGs was developed to include 10 single-system examinations and clarification of definitions for multisystem examinations. Those guidelines are referred to as the 1997 DGs. The original intent was to replace the 1995 with the 1997 DGs. However, many physicians objected because they perceived the 1997 DGs as too complicated and having the potential to detract from patient care. Therefore, in April 1998, HCFA instructed Medicare carriers to use both the 1995 and 1997 DGs when reviewing records, and physicians could use whichever set of guidelines was most advantageous.
Draft 2000 E/M documentation guidelines
In June 2000, revised draft guidelines were released that represented a simplification of the 1997 DGs, which contained an extensive list of physical examination elements and documentation requirements based on performance and documentation of the number of elements from the list. The draft 2000 DG physical examination requirement is reduced to three levels based on the number of organ systems examined. The review of systems is also based on the number of organ systems. For example, a detailed examination includes findings from three to eight organ systems, rather than the total number of elements examined. Thus, the counting of examination elements is basically eliminated. Medical decision making is also simplified to three levels, with clear requirements that can be cross-referenced to clinical vignettes currently under development. (For a look at those levels, see p. 156.)
HCFA will pilot-test the draft 2000 DGs, and continuing education will be provided for their implementation. The final guidelines likely will be adopted in 2002. Until then, providers should continue to use either the 1995 or 1997 DGs, whichever are deemed more advantageous. Regard-less of the DG version used, a properly documented patient record is an essential component of good clinical care and necessary to support the level of E/M service code submitted on a claim. When care is not properly documented (for example, inadequate or nonexistent documentation), improper payments result. In addition, according to the Office of the Inspector General, audits reveal that it is not unusual for well-intentioned physicians to code as much as two levels apart for identical services because of varying interpretations of definitions of CPT histories, physical examinations, and medical decision making.
To see the draft 2000 DGs, or to download all three versions of the DGs, go to http://www.hcfa.gov/medicare/mcarpti.htm and scroll down to the heading Documentation Guidelines for Evaluation and Management Services. Click on the Town Hall Presentation (MS PowerPoint).
(Editor’s note: Michelle A. Green is co-author with JoAnn Rowell of Understanding Health Insurance: A Guide to Claims Processing. She can be contacted at [email protected])
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