Evaluation and management guidelines

By Thomas Brandecker, M.D.

The recent flood of articles regarding HCFA Documentation Guidelines for Evaluation and Management (E/M) Services could lead one to believe these were just developed. In fact HCFA announced its intention to develop documentation guidelines in 1992. The AMA felt it could do a better job than HCFA. In consultation with medical specialty societies the AMA developed the guidelines physicians have been using since 1994. The guidelines were intended to improve the quality of medical records and continuity of patient care. They were also intended to provide physicians and claims reviewers common ground from which to work.

This was another step in the evolution of the medical record. There was a time when the medical record was primarily a communication device among physicians and other health professionals. Records evolved next to become the playground of the malpractice lawyer. Since 1992, it has become commonly accepted that the medical record serves many tasks and people, including reviewers from many insurers and most recently for quality of care indicators by managed care companies (and some would say to reduce bonuses due physicians).

Some concerns were voiced about the intrusion of HCFA and claims reviewers into physician practices and medical records but the outcry then was mute compared to the current volume of complaints with this revision. No major effort was taken to stop the process. One cannot detract from the efforts of the AMA Current Procedural Terminology (CPT) Panel because it is likely the HCFA solo effort would have been even less physician-friendly. However, if physicians had resisted the intrusions then, we may not now be headed down this slippery slope to complete loss of professional autonomy.

The original E/M guidelines were used in post-payment reviews to determine if the correct level of service had been billed and payed. With the recent emphasis on cost savings through curtailment of fraud and abuse this activity has increased. Since the guidelines were general, there was opportunity for legitimate differences of opinion as to which code was in fact correct. Unfortunately, innocent errors in coding have been labeled fraud and abuse. The new guidelines released in May 1997 were an attempt to help remedy this problem. However, the new guidelines call for increased fines (up to $10,000) and in some instances criminal penalties. They also mandate prospective reviews of one percent of all claims. This means that random records would be reviewed before payment. This is a major departure from the current method of primarily auditing outliers. Thus, in effect, physicians have to prove they are correct before there is any hint anything is wrong.

The new E/M guidelines were jointly developed by HCFA and the AMA, again with input from medical specialty societies. These guidelines took effect October 1, 1997. Surprisingly, most physicians were unaware of this. HCFA originally planned a three month “grace period” when both the old and new guidelines would be accepted. Beginning January 1, 1998 physicians were to be held only to the new standard. The AMA, expressing concern that this was insufficient time to educate physicians regarding the content and use of the guidelines, persuaded HCFA to delay implementation until July 1, 1998.

The new Documentation Guidelines for E/M Services are 48 pages long. The document describes in detail the anatomy of a code. First, the components of the history are described. Then, the guidelines for a general multi-system exam and ten different single organ system exams are presented. Each of these is broken into system/body areas which are further subdivided into “bullets.” Next, it describes documentation requirements for the complexity of decision making component. Finally, the level of service to be used is taken by how many of these different elements are documented in the record for that visit.

These guidelines are so complex that many physicians have not tried to understand them. Those of us who have to tried to make sense of these guidelines have yet to find a way to concurrently practice medicine and follow these rules. It is not reasonable to either memorize all of the components, particularly if one cannot always use the same organ system exam, or flip through 48 pages of material each time you see a patient. Attempts by medical specialty groups such as the American Society of Internal Medicine have managed to condense the main elements to both sides of a legal sized paper, and Cabot Marsh Corporation has one down to the size of a large postcard (but requires good knowledge of the guidelines).

A representative of Highmark, our local carrier for Medicare, tried to explain the highlights of the guidelines to my group in the fall of 1997. An hour later, she still had not covered all the components, and the physicians in the group were no closer to using properly the guidelines (but at least knew they existed). On questioning how one was to actually see the patient and code the visit, she indicated that physicians may need to code in the manner in which hospitals do, that is after the visit with a coder examining the record to determine which level of service the record supports.

This to most physicians is a ludicrous suggested course. First, most of us do not currently hire “coders” and cannot afford to do so when Medicare pays so little compared to charges and other insurers. Secondly, this will detract from patient care as doctors become so concerned about the medical record that we will not be focused on the care the patients actually receive. Finally, it is difficult to record all aspects of a medical encounter. So many important aspects are communicated by features such as body language and tone of voice that the record cannot convey what transpired. An experienced clinician knows much about the patient in the first minute by these techniques. Words cannot describe how the patient looks, but often we know the patient is “sick.” This is the art of medicine. It is what we try to teach students and residents at the bedside because they cannot learn it from books. The record cannot easily describe it and we should not try to do this. Our time is better spent in the care of our patients, not as scribes or as defendants explaining our codes to bureaucrats. We are fast approaching the moment when it takes longer to document what we do than it takes us to do our jobs. When we cross that line, something very valuable will be lost forever.

Patients will not benefit from these new guidelines. Research will not benefit and physicians will not benefit from these new guidelines. HCFA thinks it will benefit by reducing expenditures to physicians, but it will not. Taking into account development costs, education costs and monitoring costs, overall health care costs will rise with a smaller proportion going to patient care. This fiscal and demoralizing blow will further reduce the willingness and ability of physicians to see the uninsured and even those in plans such as Medicare and Medicaid.

Thomas Brandecker, M.D., is president-elect of the Pennsylvania Society of Internal Medicine.