Coding evaluation and management

By Thomas W. Reinke

The long-awaited guidelines for coding of evaluation and management services (E&M) by specialists have been released by the Care Financing Administration (HCFA). The guidelines specify exactly what organs or body areas must be examined and documented when specialists perform a single organ system examination. The new specifications fill an important void in coding instructions. Until now, the E&M coding guidelines have described the requirements for multi-organ system examinations, but they have been unclear about the requirements for specialists such as ophthalmologists, who focus on one area of the body.

While the primary focus of the guidelines is specialty or single organ system examinations, they also contain new information about multi-system exams and plus the other factors that must be taken into consideration when a physician selects among the different levels of visit codes.

The new guidelines send important messages to specialists and primary care physicians about the expectations for scope of work in an examination and exactly how an entire E&M service should be documented. HCFA reiterates that complete documentation is required. The leverage behind this demand is the rapidly expanding number of coding audits performed by HCFA and other federal agencies. The level of detail in the new guidelines will make audits easier because there is little room for debate about whether or not the requirements are met. For the first time, examiners will have a tool to audit E&M coding by specialists, thus providing a rationale for expanding audits among the largest segment of practicing physicians.

The new guidelines are scheduled to become effective January 1, 1998 for exams in the following areas: Cardiovascular; Ear, Nose Throat; Eye; Genitourinary (female); Genitourinary (male); Hematologic/Lymphatic/Immunologic; Musculoskeletal; Neurologic; Psychiatric; Respiratory; and Skin.

Over the past couple of years laser-like attention has been focused on these guidelines. For a comprehensive visit, the original guidelines required checking up to 10 organs, so specialists were concerned they would be forced into exams that went beyond the systems normally associated with their specialty. Some of the specialty societies proposed exam elements that were comprehensive for a specific organ but failed to include basic assessments of the patient’s general physical condition. However, third party payers and HCFA were looking for broad based exams that covered related organ systems, or required that the physician look at other aspects of the patient’s health or illness. In the end, the government prevailed.

The essence of the guidelines for specialists is that, to reach the higher level and more complex visit codes, they must perform a thorough examination of the patient that goes beyond the specific organ system of their specialty. For example, a cardiologist performing a comprehensive exam must examine the liver and spleen. A surgeon performing a genitourinary examination is required to examine the neck and thyroid as well as perform an assessment of respiratory effort and an auscultation of the lungs.

There is some logic in the details for each specialty exam. The elements that must be covered vary by specialty and generally are relevant to a particular specialty. Also, there are both mandatory and optional elements to be covered in an exam, based upon the diagnostic or therapeutic path the doctor is following. However, there may be some inequity in the amount of work required in different specialties. An oncologist performing a comprehensive exam is required to look at nine organ systems, while an ophthalmologist is required to cover only two. This variation increases the potential for the argument that RVUs or reimbursement should also vary.

While the document primarily focuses on specialty examinations, there are also new guidelines for general multi-system examinations. In addition, the document provides new information on the other major components of evaluation and management services—the history and medical decision making. All three components—a history, an examination and medical decision making—must be present in the higher E&M levels. The document clearly restates the extent of the history and the complexity of decision making that go along with the exam to comprise each visit level.

One of the greatest complaints from physicians about the previous E&M coding guidelines has been about the extensive documentation that must justify the level of the visit. Physicians argued that they implicitly use a clear, structured process to reach a diagnosis or treatment decision and therefore, it was not necessary to document this process. HCFA, however, wants documentation and the new guidelines go beyond previous versions in laying out record keeping requirements. Documentation must be provided for all of the required elements in a physical examination plus some of the optional elements. However, the amount of documentation varies by specialty. In a comprehensive ear, nose and throat exam, 23 of the 27 exam elements listed in the guidelines must be documented. By contrast, an ophthalmologist is required to document 13 exam elements.

It is likely that the new guidelines will aid the work of HCFA examiners who audit physicians for their coding patterns. These audits commonly focus on the lack of documentation to support the level of coding and the related charges submitted to Medicare. Since the new guidelines eliminate much of the confusion about what’s required, auditors may have an easier task of measuring compliance among specialists. By the same token, it is possible to develop forms or other aids which structure visit documentation so it is easy to determine if the new guidelines have been met.

It has been reported that HCFA will not be involved in extensive training efforts for the new guidelines. According to previous reports, the specialty societies have been asked or instructed to help get the word out to physicians. Training on the new guidelines is also available from qualified consultants.

Thomas W. Reinke is with the Health Care Consulting Department of Miller, Glusman, Footer & Magarick, P.C. in Philadelphia.