Medicare documentation guideline changes

By James R. Blakeman

On April 27, the AMA and HCFA brought together in Chicago, in what was called the AMA “fly-in”, more than 275 representatives of specialty societies to unveil proposed changes to the Medicare documentation guidelines. They unveiled some very important proposed changes to the guidelines that will prove favorable to practicing physicians if these are implemented. It was also announced that the 1997 changes to the exam rules will not be made and that all official changes to the rules have been delayed indefinitely.

Most observers expected to hear revisions to the 1997 exam rules, which practicing physicians almost universally rejected as burdensome and clinically irrelevant. We now know that a major re-design of the evaluation and management coding system is under way. A final version of the new rules will not be available for months, but we know the following changes are likely. Here’s what is on the table for consideration presently.

History Component

Previously, scoring E&M documentation of the history component depended upon content in the history of the present illness (HPI), the system review (ROS) and the past medical, family and social histories (PFSH). The new rules allow you to choose two of these three parts of the history in order to meet the documentation requirements.

For example, if your content includes an extended HPI and a complete ROS history consistent with a Level 5 E&M service but your past medical, family or social history is deficient, the 1994 rules made you down-code to a Level 4. Now, you can choose to eliminate the PFSH score and code consistent with the two other elements. Or, if your PFSH and HPI were adequate but your ROS was deficient, you can eliminate the ROS and score according to the HPI and PFSH.

This would eliminate the most common documentation deficiency in most physician records, the lack of an adequate ROS. But, the new rules also make a complete ROS much easier to achieve by reducing the number of organs needed for a complete ROS from 10 to five. A detailed ROS would require only two to four organs to be commented upon.

Just as good news is the elimination of the eight HPI descriptors: location, quality, severity, etc. These are now replaced with the need to note four “historical items” about the presenting problems or, to note three acute, chronic or inactive conditions. HPI documentation, which physicians have worked to improve, will meet the new “historical item” requirement, but the category is now broader and more inclusive. For example, multiple “quality” statements would each count individually toward the four item requirement, where the previous rules would allow the descriptor to be counted only once toward the four descriptor requirement.

Most important for physicians treating acutely ill and elderly patients is the clear inclusion in the new guidelines of the following: “Documentation of the circumstances related to the inability to obtain a history will be deemed equivalent to a comprehensive history.” Xact Medicare in Pennsylvania has been unwilling, as have other carriers, to allow for this in recent audits. The new rules would put this issue to rest.

The clear message from the AMA and HCFA presenters was that the 1994 rules placed more emphasis on the history component than was necessary to appropriately represent the work value of an E&M service.

Exam Component

The single organ system/general multi-system exam structure has been scrapped completely. In its place is a menu of all of the elements that previously were contained in the 11 different exams. Several new elements also appear, and the AMA promises to include many more in the coming months as this re-design of the rules continues. Physicians can choose from among the more than 175 different elements on this menu those that are clinically relevant to the patient. Scoring the exam will be a matter simply of counting the number of elements documented in the record.

The exact number of elements needed for each level has not been determined yet, but will likely be one of the following options for various exam types. Problem focused: one element; Exp. problem focused: five or six elements; Detailed: 10 or 12 elements; Comprehensive: 15 or 18 elements.

Previously, for Level 5 exams, elements had to be collected from a certain number of organs (eight organs in the 1994 rules, nine organs in the 1997 rules). The new rules will likely not specify any organ requirement, though this may change in the re-design process.

Maybe the best news is the elimination of the presumptive performance requirement that presumed performance of many more elements than were documented. Under the 1997 exam rules, if you documented 18 elements in the general multi-system exam, you might have been expected to perform as many as 26 additional elements. This was a major concern of most practicing physicians.

Medical Decision Making Component

Changes in medical decision-making (MDM) are mostly positive, but may present some problems for physicians in the future. MDM has been reduced from four types (straightforward, low, moderate and high) to three. The “low” level of MDM has been eliminated. What previously scored as low is now considered straightforward. This elimination will require that all levels of care using it be re-defined, which will now require straightforward decision-making.

Previously, MDM required that two of three elements (number of diagnoses and management options, amount of data, and risk of complications) be met or exceeded to achieve the level of service. Now, MDM is defined by the highest of the three elements and we may code to the highest single level that is documented.

HCFA and AMA representatives pointed out that those E&M levels that were defined with “low” decision-making would have to be re-defined. The big question becomes, Will HCFA reduce payment as a result of lowering the work value of some of these requirements? That will be part of the discussion as this re-design process continues.

Further Changes Certain

From here, the re-design process returns to the AMA, which will collect comments from the April 27 meeting and those offered by specialty societies in the coming weeks. The AMA’s CPT Editorial Panel was scheduled to meet in late May to make their recommendations to HCFA, which will review these and work with the AMA to produce a working version by the end of August. Field-testing and training will then begin with a feedback process that may produce yet more changes before the final version is published. Carriers and specialty societies will thereafter begin the educational process with practicing physicians.

It was made very clear by comments from representatives of the AMA, HCFA and the Office of the Inspector General that no final version can be available before January 1999. This means that an educational period might extend through April 1999 or, more likely, July 1999 before enforcement begins. Until then, carriers are now being instructed by HCFA, when auditing charts, to use the 1994 rules or the new 1997 proposed exam rules, whichever are more favorable to the physician. In most cases, only ophthalmologists and psychiatrists would benefit from the 1997 rules, since they were prohibited by some carriers from billing high levels of care without a multi-organ exam.

This is a landmark event in the development of the E&M coding system. It has many favorable implications for physician reimbursement; however, we must recognize that this is clearly a work-in-process and could negatively affect payment if levels of care are re-defined, or if RVU work values are reduced as a result of this process. For now, the news is very good, but continue to pay attention to your existing documentation practices. Complying with the rules as described in the 1994 Medicare documentation guidelines will assure appropriate Medicare reimbursement and will help to keep you off HCFA’s fraud radar screen.

James R. Blakeman is vice president of Practice Management Services, Healthcare Business Resources in Bala Cynwyd, Pennsylvania.