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Coding Consult: E&M--Out with the new, in with the old


As CMS struggles to improve documentation guidelines, here's a refresher on how to best use the current system.


Coding Consult

E&M: Out with the new, in with the old

As CMS struggles to improve documentation guidelines, here's a refresher on how to best use the current system.

Susan Callaway, CPC

Remember those much-promised new documentation guidelines for E&M coding? Well, forget them—at least for now. The Centers for Medicare & Medicaid Services (formerly HCFA) recently canceled its contract with Aspen Systems for developing the guidelines because specialty organizations that had reviewed the work-in-progress felt it wouldn't improve the current system.

So the effort is back to square one, which implies that physicians will be wrestling with the prevailing guidelines for two or three more years—at least. With that in mind, here's a refresher.

CMS has two sets of recommendations on documenting E&M services, one published in 1995 and the other in 1997. Physicians can use either. During an audit, local Medicare carriers must use the one that will give the best result to the physician.

The guidelines differ in two areas: determining the level of history of present illness for physicians documenting the status of three or more chronic conditions, and, most important, the method for documenting and choosing the level of examination.

For the history of present illness to qualify as an "extended history," the '95 guidelines require that physicians document at least four of the following eight elements: location, duration, timing, context, quality, severity, modifying factors, and associated signs or symptoms. Often, when updating many chronic conditions, you ask the same questions for each condition, but those questions don't meet the criteria for the higher category of HPI.

The '97 guidelines allow you to code for an extended history if you update the status of at least three chronic or inactive conditions. Note: To use this rule, you must also use the examination guidelines from 1997 for that patient encounter—no mix and match between the '95 and '97 rules.

For examinations, the differences in the two sets of guidelines are more pronounced. The descriptions of "expanded problem-focused" examination and "detailed" examination in the '95 guidelines don't clearly indicate what documentation is required for each level. And a comprehensive examination is defined only as encompassing eight or more body systems, or "a complete examination of a single organ system."

Because there are no specific parameters, an audit's outcome hinges on the auditor's interpretation of the level of service. The '97 instructions address this problem by specifying the number of elements required to verify each examination level.

Physicians are given a general multisystem list and lists for 11 single-organ system exams. The level of examination is determined by the number of "bullets" or examination elements included in the documentation, depending on which examination category you've chosen (multisystem or single-organ).

This method, unfortunately, has its own problems. The requirements—particularly for a comprehensive examination—are rigid and don't necessarily follow standard exam protocols. You might not get credit for some things you do because they don't appear on a given list.

For documentation of codes requiring a comprehensive examination (99204-05, 99215, 99244-45, 99254-55, and 99222-23 are the ones most practices are likely to use), think about whether you're conducting a single- or multisystem exam. When multisystem, documentation of eight organ systems, as defined in 1995, is easiest. If single-organ, you might find it preferable to use the bulleted lists provided in the 1997 guidelines.

If you opt for the 1995 guidelines, make sure your documentation covers all areas of the given organ system, as well as other systems that are commonly involved in such an exam based on the diseases treated by your practice.

And remember:

• You aren't required to use the same set of guidelines for each patient, or even for different encounters with the same patient.

• You don't have to declare on the chart which guidelines you're using, since the CMS auditor must use all available guidelines before making a final determination of the best level of service.

• Only CMS auditors must use the guidelines that give the best result to the physician; other insurers may have different guidelines for audits.

So focus on documenting completely all elements of the examination, as well as the history you've taken. If you document well, you should be able to ace any audit.



Susan Callaway. Coding Consult: E&M--Out with the new, in with the old. Medical Economics 2002;3:20.

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