by Jennifer Della’Zanna, CPC, CGSC, CMT
If you’re not an expert evaluation and management (E/M) coder, the mere mention of the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services might make you a bit tentative. And if you’ve been guessing about how to apply these guidelines, the idea of an audit might make you cower under your desk. Checklists, forms, and templates abound, and most of them are confusing unless you already know what you’re doing.
But if you read the guidelines one section at a time, taking breaks before your eyes glaze over, it’s really an application of common sense that emerges as the best way to tackle this problem.
1995 E/M guidelines
When the AMA introduced E/M codes in 1992, there was little direction for physicians regarding their use. The first audit of those codes showed such high error rates that CMS (then the Health Care Financing Administration) released the 1995 Documentation Guidelines for Evaluation and Management Services to quantify the information needed for each key component (i.e., history, examination, and medical decision-making). The guidelines provided rules about specifics physicians need to document for coders to assign the different levels of E/M visits. You simply have to count elements of history, exam, and medical decision-making to determine each component level, and then compare these levels to the different code requirements.
The 1995 guidelines provide a great level of detail regarding the history and examination elements, but leave medical decision-making relatively vague. This, in turn, led physicians and coders to assign codes based on those components that they could easily quantify, giving negligible importance to the medical decision-making component, which is the section that speaks directly to medical necessity. Many physicians say that medical necessity should be the driving force behind code selection, and it is certainly the main reason auditors downcode many E/M services. Certainly, this element is the hardest to quantify, although it makes sense that the most difficult presenting problems should be the ones that command the highest code levels.
Another difficulty that arose with the 1995 guidelines was that the requirements for a comprehensive physical exam were very broad. So physicians who performed more problem-focused or expanded problem-focused exams, but at much higher levels than general practitioners, were precluded from reporting higher level E/M codes, even though they better reflected the services performed.
1997 E/M guidelines
To address some of these problems, CMS introduced the 1997 Documentation Guidelines for Evaluation and Management Services. The differences between the two sets of guidelines lie mainly in the portion that addresses the examination. The 1997 guidelines provide additional options for quantifying component levels by providing bullet points for single organ system examinations so that documentation becomes more of a checklist of items. Having a certain number of items documented means you may report the next code level. This allows providers to report higher level services for intensive problem-specific examinations.
This means that physicians must document many individual normal findings by name to achieve a certain level. For example, the 1995 guidelines allow physicians to document an entire organ system as “normal” to indicate that system was examined. But the 1997 guidelines require physicians to document a number of bullet points within each system to attain each level.
Sample case for code 99203
According to CPT Manual guidelines, a detailed examination level requires an “extended examination of the affected area and other symptomatic or related organ systems.”
Consider an example in Appendix C of the CPT Manual for code 99203 of an initial office visit for a 30-year-old female with pain in the lateral aspect of the forearm. To report code 99203, documentation must support a detailed examination.
The 1995 guidelines define “extended” as “two to seven systems,” so it would be acceptable to code for a detailed examination when documentation included details about the affected extremity, and also a notation of “normal” for skin and neurologic systems.
1997 guidelines allow physicians to include details about two systems or areas for a detailed exam. However, this examination must include specific mention of at least 12 prescribed bulleted elements from the systems or body areas. If you look at the Elements of Examination chart in the guidelines, you will see that the musculoskeletal system provides for an examination of one extremity. However, there are only four bulleted elements listed. If you count the Constitutional system or body area as your other system, it is impossible to achieve 12 elements of examination between these two systems.
With the introduction of the 1997 guidelines, the AMA protested the additional work to document an exam such as the one I just described, and this led to the following rule: Physicians may use either the 1995 or the 1997 guidelines (whichever was more beneficial for them) to document their encounters. The AMA was happier, but of course this led to lots of headaches for coders.
Coders have to be careful to apply the rules of either the 1995 guidelines or the 1997 guidelines to any one case. Coders should be familiar with both sets of rules, and make sure that they don’t apply one guideline when assigning codes for the history section of a patient’s chart and the other guideline to the exam portion.
Medical decision-making component
In truth, decision-making should be at the heart of E/M code selection. The history and examination are there to support, or justify, the medical decision-making level. Physicians generally do as much work as is needed to determine how to treat a condition, so the problem should dictate the history and physical level.
For example, when a patient complains of a sore throat and cough, the physician is unlikely to perform an eight-system exam with a full past, family, and social history. The presenting problem calls for a problem-focused history of present illness and problem-focused examination. In this case, the 1995 guidelines would be more appropriate for determining which level code to report.
In an alternate example, suppose a patient came to a neurologist with nerve damage to the spine from trauma, multiple spinal fusions without pain relief, and new onset of intermittent episodes of seizure-like activity with negative electroencephalogram findings during an active episode. This problem obviously requires a high level of service; however, the documentation requirements for a comprehensive examination under the 1995 guidelines state, “A general multi-system evaluation or complete examination of a single organ system.”
The physician may perform thorough neurologic and musculoskeletal exams with some attention to gastrointestinal, respiratory, cardiovascular, constitutional (i.e., vital signs), eyes, nose/mouth/throat and skin. But he or she may not perform a complete exam of any one of those organ systems, meaning the examination would not meet the “general multi-system evaluation” either.
Under the 1997 guidelines though, you have the option of performing basic checks of some of the systems, with great attention paid to the systems you want to focus on. The physician would document points touched upon for basic systems and document additional elements for the more thoroughly examined systems. The documentation is a bit more significant because the guidelines require physicians to touch upon at least one or two points in each of nine areas. But the 1997 guidelines don’t hold the physician to the strict levels outlined in the 1995 guidelines of a complete single organ exam. In this case, the 1997 guidelines would serve the physician better.
Again, it is very important that you are consistent about which set of guidelines you apply for each record. Double check your documentation of both history and physical components against the rules to make sure they are all in compliance for the set of guidelines you choose to apply. For example, the 1997 guidelines allow consideration of chronic or inactive conditions in the review of systems and history, whereas the 1995 guidelines only count comorbidities.
Medical decision-making, which is the only component for which the rules are the same for both sets of guidelines, still causes distress among coders and physicians alike.
There is no universal guideline for determining a physician’s level of medical decision-making. Auditors may use several tools, such as the Marshfield Clinic audit tool or CMS’ Medical Decision-Making Point system. But it’s anyone’s guess as to which tool an auditor might use when he or she pays your organization a visit. If it turns out that an auditor uses a tool different from your own, you may want to inform the auditor of your choice of tool to illustrate that you are working to maintain compliance.
If you consistently apply one set of guidelines and only occasionally switch to the other, you may want to consider putting a note on the records of the patients who are the exceptions so that auditors can quickly determine what set of guidelines you applied.
Take caution with extensive documentation that does not seem to reflect the severity of the patient complaint. Some physicians may decide on the level of service for which they want to bill, and then document that level of history and examination to satisfy the requirements for reporting that level code. This is not compliant and is a clear case of overcoding, for which an auditor may determine a lack of medical necessity.
Let’s use the example above of the woman with pain in the lateral aspect of her forearm. The CPT Manual indicates that this would be a problem appropriate for code 99203. Suppose that the physician, using 1995 guidelines, decides this problem warrants a code 99204 visit.
The physician could look at the requirements for documenting this higher visit, which are a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity. Because she is a new patient, a comprehensive history is easy to obtain, and a comprehensive examination might be in order. To the coder quantifying these elements of the exam, the levels might clearly point to 99204. However, the differential diagnosis, the complexity of medical records and tests, and the risk of complications, morbidity, and mortality are certainly not going to indicate a moderate degree of medical decision-making to an auditor, and meaning the case more likely warrants code 99203.
On the other hand, there are physicians who see a patient for a problem that would indicate a high level code but, because the patient is established, they don’t take the time to document the inactive problems or chronic conditions within the current note that would allow the history and examination elements to match the medical decision-making.
Upon review, an auditor might downcode this claim for lacking history and exam elements, even when it was clear that the physician spent significant time with the patient and thoroughly evaluated the condition. Remember, if it’s not documented, it didn’t happen.
To prepare for potential audits of your E/M codes, take the following steps:
Be familiar with both the 1995 and 1997 E/M guidelines
Clearly apply one or the other to your charts, noting when you change from the norm for your practice
Work with your physicians to determine how to determine the medical decision-making component for each patient
With these processes in place, you can come out from under your desk and greet the auditor with a smile on your face, confident that your E/M coding is under control.
Editor’s note: Jennifer Della’Zanna, CPC, CGSC, CMT, is a coding instructor for Ed2Go, one of the largest providers of online education in the country. E-mail her at firstname.lastname@example.org.