Letter to McCann, Wooton, and Harris
April 13, 1998
Bart McCann, M.D.
Executive Medical Officer
Center for Health Plans and Providers
Group Plan and Provider Purchasing Policy
Health Care Financing Administration
7500 Security, C4-02-06
Baltimore, MD 21244-1850
Percy Wooton, M.D.
President
American Medical Association
515 North State
Street Chicago, Illinois 60610
T. Reginald Harris, M.D.
Chair, AMA CPT Editorial Panel
808 Schenck Street
Shelby, North Carolina 28150
RE: Comments on EM Documentation Guidelines
Dear Colleagues:
The Association of American Medical Colleges (AAMC) appreciates
the opportunity to provide additional comments to HCFA and
the AMA CPT Editorial Board on the new Evaluation and Management
(EM) Documentation Guidelines currently scheduled for implementation
on July 1, 1998. As you know from prior meetings and our comment
letter of January 28, the AAMC has many concerns and serious
reservations about the guidelines. This letter includes comments
that are more specific and provide further context for earlier
AAMC suggestions to refine aspects of the guidelines and to
develop appropriate policies for their use by physicians practicing
in both teaching and non-teaching settings. We hope that these
recommendations will be adopted prior to implementation of
the guidelines.
The AAMC has received nearly 100 comment letters from senior
faculty physicians, clinical department chairs, and compliance
officers representing over 50 of the 125 medical schools across
the country. These comments, and where appropriate the direct
quotes of our faculty physicians, have been summarized under
four topic areas: 1) general comments on system design; 2)
the inherent problems with the current CPT coding architecture
for EM services; 3) specialty- specific comments on the content
of the guidelines, required elements of the single organ system
exam, history and medical decision-making components of a
service; 4) compliance/audit concerns.
1. General Comments
The comments from our members reinforce the AAMC's concerns
that the purpose of the guidelines is unclear. The guidelines
are far too complex and need to be simplified; and almost
every aspect of the organization format, including the terminology
and instructions, are either not defined or confusing to teaching
physicians and the documentation requirements are overly burdensome.
An emergency medicine physician states:
"...The guidelines have more than doubled
the charting time per patient which for a busy emergency medicine
physician with eighty patients per shift, can be several hours
of extra time spent in documentation per day..."
Members also state that the guidelines do not adequately
meet the needs of specialists and their patients, in that,
they do not allow the physician to exercise enough clinical
judgement as to what is and is not medically necessary for
the patient. Further, our members state that the guidelines
lack relevancy to their everyday practice of medicine, and
are concerned that they will have a negative impact on patient
care and the specialty practice of medicine by reducing time
available for highly detailed inquiry, teaching and research
activities. A nephrologist comments that:
"...The use of these physical examination
requirements for reimbursement will almost certainly divert
a nephrologists' time and attention from acquisition of the
data for making wise clinical decisions to spending their
allotted time performing repetitions and unnecessary physical
examination routines. ...The physician with limited time will
spend it examining the patient rather than talking to them,
understanding their complaints, reviewing their laboratory
data, sorting out the multiple medications they are taking
and making the appropriate adjustments in care. In short,
I believe the new EM guidelines will have a pernicious effect
on subspecialists..."
The issue of relevancy to medical practice was raised repeatedly.
A major concern is the failure of the EM guidelines to recognize
the value of managing complex cases which have little to do
with the direct physical exam. For example, management of
a patient with inappropriate ADH Syndrome or diabetic ketoacidosis
may be extremely complicated. The management, however, is
almost entirely related to the ability to obtain appropriate
testing and to interpret the results of the chemistries. While
the physical examination is not totally without value, it
is really only a minor part of the management of many of the
metabolic abnormalities that seriously ill patients acquire.
In these clinical situations, greater emphasis on medical
decision-making is far more appropriate. Specialty medical
practice is filled with such examples.
Purpose
HCFA should clarify the purpose of the guidelines as documentation
requirements, performance requirements or both documentation
and performance requirements. The document title itself communicates
an inaccurate message since throughout the guidelines HCFA
discusses both physician work (performance) requirements and
documentation requirements. It is evident to many of our members
that the guidelines were developed for the singular purpose
of promoting the audit process. Our members believe that the
more relevant purpose of the guidelines should be to improve
the documentation of care and perhaps contribute positively
to patient care and teaching activities as well. The current
version does neither. It does articulate a set of burdensome
and rigid performance requirements and some confusing documentation
instructions, much of which are irrelevant to specialists
and to teaching physicians.
Format and Terminology
Revisions to the guidelines should strive to improve their
organization and format, as well as define terms. HCFA should
eliminate the both confusing "shaded/unshaded" categories
entirely and use of "bullets" to characterize the
exam elements. As we recommend in this letter, creation of
a master list of elements and permitting physicians to select
from among this listing a specified number of elements appropriate
for any given exam, will eliminate much of the current confusion
and simplify the process, while maintaining a basic common
level of work for payment purposes. If the revised guidelines
cannot be communicated effectively, then the confusion and
concern that all sectors of the physician community are voicing,
will of necessity, continue.
Continued use of the phrase "documentation guidelines"
is misleading and inaccurate, as the term implies that the
guidelines refer only to documentation, and are optional or
perhaps discretionary. In fact, as currently written the guidelines
define both: 1) the requirements for physician work to perform
in order to bill a level of service, and 2) the instructions
for the physician on what to document. The AAMC recommends
that the guidelines focus ONLY on documentation instructions
and that HCFA relegate work performance requirements to a
different set of instructions entirely. This may avoid confusion
over the distinction between work and documentation requirements.
However, if HCFA decides to maintain the current approach,
the AAMC suggests that the revised instructions be entitled
"Medicare Program: Physician Performance Requirements
and Documentation Guidelines for EM Services". This
title explicitly communicates the dual nature of the instructions
as: 1) the specific physician work activities that must be
performed in order to bill a given level of service, i.e.,
history, exam elements, medical decision-making; and 2) the
general documentation "guidelines" to substantiate
a level of service performed, whereby documentation by the
physician is a somewhat more subjective process and variable
depending upon the type of visit service and the patient's
medical condition. For example, teaching physicians have the
flexibility to incorporate, to summarize, and to refer to
the detailed note of the resident to the degree that the teaching
physician believes it is appropriate to substantiate the bill
for a particular patient.
Given that teaching physicians have special instructions
relative to their personal work and documentation in order
to substantiate a bill when a resident is involved in the
service, HCFA should include a section on these special instructions
in the revised document, in the 1999 edition of CPT, in its
educational materials, and in all other communications on
this topic. Both the role of the teaching physician and the
resident should be addressed. In the context of this letter,
we have suggested some instructions that should be included.
2. CPT Coding Architecture for EM Services
Improvements to CPT
Everyone appreciates the need to preserve a resource-based
approach to the EM coding system and, for the most part, the
relative value units (RVUs) assigned and recently updated
for over 7400 physician services appear to be satisfactory.
This was an enormous project to manage and complete. However,
steps should be taken to modify the coding system in ways
that improve its utility and application, but obviates the
need to recalculate physician work RVUs for EM services. We
are confident that a combination of coding changes and new
policies can accomplish this objective.
When first designed in 1990-91, use of the EM coding system
should have been implemented as a short term solution to satisfy
the immediate needs of a resource-based relative value payment
system. Since that time, HCFA and the Office of Inspector
General have conducted some limited studies of how the EM
codes are being used by physicians. Even these limited studies
have revealed significant flaws and a lack of physician understanding
regarding coding descriptors and the selection process.
It is time to reevaluate the EM coding system in order to
assess its long term value and relevance to medical practice
in both teaching and non-teaching settings. The EM coding
system has become the vortex for the most significant issues
and complaints physicians in every specialty raise about the
Medicare payment system. Designed in the context of a vastly
different payer/provider environment, under a vastly different
set of priorities, the problems with the EM coding architecture
are manifest today in an environment that is primarily concerned
with the discovery of physician fraud and abuse. Physicians
are entitled to have a coding system that does not perpetuate
a practice environment riddled with accusation, anxiety, and
legal risk.
While a complete over haul to the current CPT coding architecture
for EM services may not be necessary, the existing system
does require some change. Our members believe that there is
little likelihood that we will ever achieve a reasonable solution
with modifications to the guidelines alone unless these modifications
are implemented in conjunction with changes in the EM coding
architecture. The two are intimately intertwined. The AAMC
has raised this issue in prior comment letters to HCFA and
in a 1997 issue brief to the CPT Editorial Panel Executive
Committee. Many members continue to have serious doubts regarding
the preservation of the current EM coding architecture.
The AAMC concurs with our members' views that the current
EM architecture is unnecessarily complex and should be simplified.
The guidelines impose yet another level of complexity over
the existing architecture with little, if any, attempt to
rationalize the system as a whole. We simply must assure that
the combination of these instructions do not create an unreasonable
burden for physicians.
At this time, we wish to make the following suggestions:
Emphasize Medical Decision-making Activities
Many of our members comment that the components of an EM
service should be weighted differently. They believe that
the real value of a physician's service is in the medical
decision-making and not in the history taking or even exam
activities. In teaching settings, taking of the patient's
history is a relatively simple process, and in a world of
sophisticated medical technology and diagnostics, the physical
exam often provides only limited information. It is the medical
decision-making activities of the specialist that incorporate
evaluation of the history, exam findings, and review of test
results, procedure reports, etc., that drives the establishment
of a diagnosis and the plan of care. It is the physician's
expertise and "cerebral energy", deployed to accurately
interpret and combine the findings of all three visit components,
that should be given greater weight in the EM coding and documentation
process.
Simplify the History Selection Process
History of Present Illness
The history requirements for consultations and comprehensive
visits are too repetitive and should be simplified to include
a chief complaint, and appropriate history of present illness
that includes appropriate review of systems (ROS) (see comments
below on ROS changes). The ROS should be incorporated into
the history of present illness (HPI) as a single element since
the HPI requires an inquiry into associated signs and symptoms
which requires a ROS. The current separation into two elements
creates an artificial distinction which does not exist in
practice. In addition, HCFA should:
- Redefine the "interval history" (codes 99231-33)
for subsequent hospital and follow-up visits for established
patients that is an abbreviated level of history more appropriate
for visits with established patients. An interval history
might require a chief complaint with history of present
illness and ROS as selected by the physician. Emphasis for
these visits should be on medical decision-making activities
and more work "value" shifted to this component
of the visit service for established patients.
- Consider adopting a point system so that physicians can
quantify their selection that combines ROS and HPI elements.
Review of Systems (ROS)
With regard to the ROS, as currently structured the higher
level codes pose significant difficulty to specialists and
generalists across the spectrum. The gradation to the next
higher level of ROS, in particular from a problem focused
to a detailed, seems inconsistent with the work required of
the physician. For example, the required systems to review
for a problem focused ROS is none; for an expanded problem
focused ROS is 1; for a detailed ROS is 2-9 systems; and for
a comprehensive ROS, 10 systems must be reviewed.
The requirement that a physician perform a review of all
10 systems in order to satisfy the requirement for a comprehensive
level exam, is often not relevant to either the specialty
practice of medicine or the patient's medical condition for
which specialty care is required. For example, a specialist
examining a critically ill patient with congestive heart failure,
is likely to perform a comprehensive evaluation although his/her
focus may not include all 10 systems, but rather a more thorough
evaluation of 6 systems that are most relevant to the condition(s)
of the patient. Our members believe that a physician should
not be precluded from choosing a level that requires a comprehensive
ROS because he/she did not meet a 10 system requirement, when
the work performed was equivalent or exceeded that required
in a 10 system review. The clinical value (relevance) lies
in addressing certain systems in greater detail and physicians
should not be required to ask clinically irrelevant questions
of sick patients merely to satisfy coding requirements. The
AAMC believes that this is a critical issue and must be resolved.
Therefore, we recommend that HCFA adopt a policy that allows
the physician to assess their work in a way that represents
intensity of effort within a system as well as across systems.
The simplest, most direct way to achieve this is for HCFA
to adopt a more consolidated gradation for the ROS requirements.
Our members suggest that a detailed ROS should require 2-5
systems and a comprehensive ROS should require a minimum of
6 systems. The present 10 system requirement is excessive.
This change is reasonable, more accurately accounts for physician
work, and could be implemented easily. It would allow far
more flexibility to specialty physicians and improves the
clinical relevance of the specialists' work, time, and intensity
while encouraging efficiency. It would enhance a physician's
satisfaction with the system. The patient would benefit by
not being subjected unnecessarily to irrelevant clinical questions
and hopefully, improve patient satisfaction with their care.
We believe this change merits your serious consideration and
is consistent with the intent of the Medicare fee schedule
system while preserving its resource-based methodology.
Simplify Selection of Medical Decision-Making
In order to assess the level of his/her medical decision-making
(one of the three required components of an EM service along
with history and exam) a physician must consider a plethora
of factors and grids. One member commented that:
"It is actually more complex for the physician
to determine the proper reimbursement level than to make decisions
with respect to the patient's care."
Our members believe strongly that the current CPT requirements
and approach need to be greatly simplified. Currently, the
amount of effort a physician must invest attempting to determine
his/her level of decision-making is untenable. They recommend
a number of options:
- Reduce the number of elements for medical decision-making
and aggregate them into one matrix rather than spread them
across three tables. Reconsider and refine a point value
for all medical decision-making activities. In a matrix,
equate the total points with a specific level to determine
if the medical decision-making is straightforward, low,
moderate or high.
- Develop selection criteria by primary and secondary diagnoses,
or a combination of diagnosis and management options.
One member states that it would be helpful to clarify further
the difference between moderate and extensive levels for the
"amount and/or complexity of data to be reviewed",
and between moderate and high levels for the "risk of
complications and/or morbidity or mortality".
The AAMC recommends that HCFA consider the merits of expanding
the Table of Risk to correspond to four levels and allow physicians
to use this as a gauge for medical decision-making. This would
be very helpful and easily implemented. Linking medical decision-making
levels to the clinical vignettes already developed and included
in CPT may also be helpful to illustrate the selection process.
Simplify Nomenclature, Reduce Coding Levels and Adopt Consistency
in Selection Options
First, our members state that the nomenclature to indicate
the complexity of care that is used across the key visit components
of history, exam and medical decision-making is too complicated
and confusing to be easily remembered, requiring physicians
to carry pocket reference cards at all time. Our members urge
HCFA to adopt a more uniform nomenclature across the visit
components.
The AAMC has commented previously that the EM coding architecture
encompasses too many levels within codes that prompts inconsistency
in their use from physician to physician. While the attempt
initially was to match resource utilization with the appropriate
payment, the concept and methodology perhaps was taken too
far. The levels within codes are difficult to substantiate
in the documentation. Due to the subjectivity in the process
of selecting the "correct" code for a visit service,
it seems improbable that a physician and an auditor would
agree on the appropriateness of the code billed for a particular
service. Physicians believe that the system leaves them vulnerable
to accusations of fraud and have begun to systematically "down-code"
their services as a means of minimizing unintentional billing
errors.
In line with our recommendation to limit the number of levels
to four for all EM services, the AAMC recommends that HCFA
revise the current levels for initial hospital care services
(99221-99223) and Observation Services (99218-99220) as follows:
- Create a new "level 1" for these services that
is defined with "an expanded problem focused history
and exam with straightforward or low medical decision-making".
The corresponding time would be 15 minutes for the initial
hospital care service category. The other levels for these
categories would not change.
The addition of this new level for initial hospital care/observation
services would provide an appropriate and useful option to
reflect the work performed by teaching physicians when residents
are involved in providing the service. The new level would
also reduce the use of modifier 52 and improve compliance
with the documentation instructions for teaching physicians.
Additionally, some members commented that time should be
adopted as a fourth component used to determine the level
of service in addition to the other three components of history,
exam and medical decision-making. For example, it might take
much longer to obtain information and to examine an elderly
patient, or a patient may have multiple but straightforward
medical problems requiring less complex decision-making but
extensive time to complete the history and exam. In both cases,
the physician may not be able to meet the requirements to
bill a detailed or comprehensive level exam. Our members believe
that these types of patient situations should be resolved
and that time be acknowledged as a valid proxy for physician
work, included as a criteria for selection, and be applied
to all EM services and not just counseling.
To simplify the coding architecture, our members recommend
that HCFA develop a logical, straightforward coding process
utilizing no more than four levels of history, exam, and medical
decision-making as defined by CPT. The EM service codes should
be restructured so that each type of service has the same
levels, including visit and consultation service codes. Variation
may be required by delivery site, given that hospital patients
typically require more intensive services than ambulatory
patients. Intra service time (defined in CPT as "face
to face" time spent with the patient for office and outpatient
visits, and as "floor/unit" time for inpatient visits)
should also be added as the fourth factor for selection with
equal weight. We have provided additional comments on the
use of time below.
To illustrate:
Level Med. Dec. Mkg History Exam Time
1 straightforward problem focused problem focused xx
2 low expanded problem focused expanded problem focused xx
3 moderate detailed detailed xx
4 high comprehensive comprehensive xx
Reconsider Physician Encounter Time as a Key Factor in Selecting
an EM Code
Another option to simplify the selection among EM codes is
to include average physician encounter time among the key
factors of the visit service, and to permit selection based
on time as well as the extent of history, exam, and complexity
of decision-making. Physician intra service time should be
recognized as a legitimate "resource cost" in and
of itself, just as the cognitive intensity of work required
by a physician to perform a history or physical exam. Intra
service time is an appropriate proxy for physician work effort
and should be included among the key factors that drive the
selection of an EM service code level in all specialties,
except emergency medicine. Our members believe that incorporating
time into the payment system for all EM services--visits and
consultations--similar to the time-based codes for critical
care services, would greatly simplify and alleviate many of
the current problems with selecting an appropriate EM service
level. Average physician times are published in CPT for most
EM visit services currently and could be incorporated easily
into the instructions for selecting a code.
Encounter time as a key selection factor, combined with documentation
that properly summarizes the personal service of the physician
relative to the other visit factors of history, exam and medical
decision-making, will assure appropriate payment is made under
the Medicare Fee Schedule system.
To summarize, we suggest that HCFA should:
- simplify the current EM coding architecture by reducing
the levels of service within each code; apply consistent
terminology to describe physician work within each level
of code; and incorporate average, intraservice physician
work time into the criteria for selecting a level of code.
- combine history of present illness and review of systems
(ROS) into one activity as one measure to simplify the selection
process.
- reduce the required number of systems to review in the
ROS for detailed and comprehensive level visit services.
- give medical decision-making activities greater weight
in the payment system and simplify the current process to
determine a level of medical decision-making.
3. Specific Issues: Multi-system and Single Organ System
Exam Requirements
Exam Requirements
Overall, teaching physicians are concerned that the required
exam elements at all levels, but especially the detailed and
comprehensive exam levels, are often not relevant to a specialty
care practice, are clinically inefficient, overly proscriptive,
and extremely burdensome to document. Also, our members state
that physicians should receive credit for the assessment of
an element deemed medically necessary, although not on the
list. These unlisted elements should be counted toward any
required element count The American College of Emergency Physicians
(ACEP) has proposed a reasonable and workable solution to
these issues. ACEP recommends that:
A general multi-system or a single organ system
examination may be performed by any physician regardless of
specialty. The type and content of examination are selected
by the examining physician and are based upon such physician's
clinical judgement.
The AAMC would expand this general policy with these statements:
Physicians that assess an element not on the official list,
but determine the element is medically necessary and pertinent
to examine, may include and/or substitute this element in
the total count of elements required for a level of service
if the unlisted element is properly documented.
The elements performed by the physician should be the elements
documented by that physician.
Further, the AAMC recommends that the ACEP proposal should
be expanded to clarify further the requirements for teaching
physicians as follows:
In teaching settings, when a resident and teaching physician
provide a visit service contemporaneously, i.e., in direct
observation of the resident's service, the teaching physician
must confirm selective key elements of the exam that are
considered most important in his/her clinical judgement.
To complete his/her personal service, the teaching physician
must confirm the history of present illness and medical
decision-making components of the service.
To substantiate the level of service billed when the service
is provided contemporaneously with the resident, the teaching
physician must write a personal note documenting selective
exam elements that in his/her judgement are most important
to restate from the resident's more detailed note.
To complete his/her personal note, the teaching physician
must also state his/her physical presence and document selective
elements that in his/her clinical judgement are most important
from the history and medical decision-making component of
the service. While the teaching physician does not need
to redocument the ROS if already detailed by the resident
or the medical student, he/she may include selective comments
relative to the ROS, as appropriate. No documentation provided
by the medical student relative to exam and medical decision-making
components of the service is acceptable for billing purposes
under the Medicare program.
Use of documentation "templates" and other standardized
check lists are acceptable as long as the teaching physician
also provides brief narrative comments for the most significant
positive and negative findings.
If the teaching physician performs the service independently,
(i.e. the entire visit is not contemporaneous with the resident),
either before or after the resident's service, the teaching
physician must perform all required elements necessary for
a particular level of exam service. For example, if a comprehensive
level exam requires xx elements to be performed, then the
teaching physician must perform personally, all xx elements.
To substantiate the level of service billed when the service
is performed independently, the teaching physician must
write a personal note documenting selective exam elements
that in his/her judgement are most important to re-state
from the resident's more detailed note.
To complete his/her personal note, the teaching physician
must also document selective elements that in his/her clinical
judgement are most important from the history and medical
decision-making component of the service. While the teaching
physician does not need to redocument the ROS if already
detailed by the resident or the medical student, he/she
may include selective comments relative to the ROS, as appropriate.
No documentation provided by the medical student relative
to exam and medical decision-making components of the service
is acceptable for billing purposes under the Medicare program.
Use of documentation "templates" and other standardized
check lists are acceptable as long as the teaching physician
also provides brief narrative comments for each of the most
significant positive and negative findings.
Requirements for Detailed and Comprehensive Level Exams
Single Organ System Exams
Flexibility is a clinical imperative for most specialists
that typically perform detailed and comprehensive exams on
severely ill patients requiring focused, yet thorough assessments.
Members commented frequently that they find it nearly impossible
to bill a level 5 service. For example, a cardiologist commented
that he failed to meet the new requirements for a comprehensive,
level 5 initial office visit although he performed 23 exam
elements, since, in the cardiologist's best clinical judgment,
it was not relevant to perform the two required elements under
the respiratory system. He failed, as well, to meet the general
multi-system exam requirements of 2 elements from 9 different
systems. The visit service was subsequently down coded by
the chart abstractor to a level 3 despite the significant
physician work effort, time and medical decision-making performed
in order to evaluate the patient and initiate a plan of care.
This situation is not an isolated incident, rather, it occurs
frequently in medical centers providing highly specialized
patient care. (See cardiology report attached.)
A neurophtalmologist comments that:
"...evaluating a patient for brain tumor
manifestations might require two hours of important exam observations
about the patient but would never be able to reach the comprehensive
exam level under either the eye or the neurologic systems.
There are three slit lamp examination elements required for
an eye examination to be comprehensive, which would be useless
for a neuropthalmology exam. On the neurologic exam, there
is a cardiovascular element required for a comprehensive level
which would be wasted energy for a neuropthalmologist."
To simplify the requirements, HCFA should adopt a policy
whereby a set number of total elements must be performed for
a single organ system exam, rather than a set number within
a specified number of organ systems. (This rule would NOT
apply for the general multi-system exam where a number of
organ systems/areas should be specified.) In essence, create
a "cafeteria" approach, whereby the specialist is
permitted to select from among a list of elements for that
specialty exam and perform the most relevant to the patient's
medical condition, keeping aligned the nature of specialty
medicine and the guidelines. The confusing "shaded/unshaded"
categories for the elements should be eliminated entirely.
Although we do not include the specific number of elements
to examine for the various levels of service, the suggested
policy for specialty (single organ system) exams is as follows:
A detailed examination requires performance of no
less than xx elements.
A comprehensive examination requires performance
of no less than xx elements.The elements performed by the
physician should be the elements documented by that physician.
The appropriate specialty societies should be asked to establish
the number of total elements to require as part of their review
of the exam content.
This approach could be expanded to create one, master list
of total required exam elements that spans across multi-system
and specialty organ system exam requirements as proposed by
ACEP. This approach would reduce complexity and confusion,
and allow the physician to determine the most important elements
to perform within each system. Since all elements are weighted
equally in terms of work, this approach seems consistent with
the resource-based methodology and should not require changes
to total work relative values assigned to these physician
services under the fee schedule. This policy, if adopted,
would provide enormous benefit to both the physician and the
beneficiary, and go a long way to simplify the current design
scheme while achieving the same goal of assuring that the
required work is performed.
Our members also suggest the following:
- pictures and marked illustrations of the body should be
allowed as part of the required documentation for the physical
exam and aspects of the treatment plan;
- documentation should include brief comments on significant
positive and negative findings for the elements selected
by the specialist for assessment.
General Multi-system Exams
For a general multi-system exam, our members favor the ACEP
proposal (with the second sentence on documentation) that:
A detailed examination requires performance of no
less than twelve elements in at least two organ systems
or body areas.
A comprehensive examination requires performance
of no less than eighteen elements in at least five organ
systems or body areas. The elements performed by the physician
should be the elements documented by that physician.
Additionally, our members support the ACEP proposal that
the general multi-system exam be modified to include all body
areas and organ system, non-duplicate identified elements,
from both the general multi-system and single organ system
exams. This approach will ease the periodic updating of the
list and enhance a more user-friendly format as to how these
elements are communicated for each specialty. For example,
a reference matrix could be developed that lists all the elements
and displays the "links" to each single organ system
exam as opposed to the current format of having eleven separate
lists of requirements. Following is an illustration of the
type of matrix that could be developed as part of the revised
instructions and for educational purposes:
General Multi-System Element Special/Single System Elements
Cardio/Genit/ENT/Resp/etc.
Cardiovascular
-Palpation of heart
-Auscultation of heart x x x x x
-Measurement of BP x x x x x
in 2 or more extremities
-Examination of: x
-peripheral vascular x
system by observation
-carotid arteries x x x x x
-abdominal aorta x
-femoral arteries x
-pedal pulses x
Organ System Performance Requirements
These specific changes have been suggested by our members
and should be included in the revised guidelines:
Pediatrics, GI, OBGYN, Physical Medicine and Rehabilitation.
- HCFA should develop a specific set of requirements for
pediatrics.
- There should be specific examinations for the specialties
of pediatrics, gastroenterology, obstetrics-gynecology,
and rehabilitation medicine.
- For OB patients, the genitourinary examination is not
appropriate. Additionally, there should be a section dealing
with pregnancy, including elements for fetal weight, fetal
heart tones, and Leopold's maneuvers.
- For physical and rehabilitation medicine, there should
be a specific set of requirements that requires elements
from both the musculoskeletal and neurological system examinations.
Also, credit should be given for documenting the functional
aspect of the patient, since this is a primary concern in
the field of physical medicine and rehabilitation. In the
history component of a visit service, functional status
should be included and credited.
Dermatology (Skin)
Although these exam requirements were revised this past December,
members still feel they require additional changes as follows:
- Revise bullet #1 to state "inspection of scalp or body
hair (face, chest, pubic area, or extremities)". The
palpation of the scalp is seldom part of the routine physical
exam.
- It is inappropriate to include "inspection of the
eccrine and apocrine glands, etc." as a vital component
of the skin exam, especially when the suggested reasons
for inclusions are for examining for hyperhidrosis, chromohicrosis,
and bromhidrosis. The frequency of those conditions are
extremely low. Eliminate this requirement as a separate
bullet. The reporting of these findings would be included
in the inspection of the separate anatomic areas of the
skin (i.e. hyperhidrosis noted in the left and right axillae).
- Nails should be moved from the extremities in the skin
exam. Nails, like hair are part of the skin and not just
a marker for possible internal problems. There are many
patients presenting with nail complaints, and they should
be addressed in the context of a complete skin exam.
- Buttocks should be a separate bullet form genital/buttocks.
There are a wide array of presenting conditions that require
careful exam of either body area but not both. Genital should
include Genital/Perineum.
- Respiratory and musculoskeletal systems should be included
in the skin exam.
- Respiratory system should have assessment of respiratory
effort and auscultation of lungs, for allergic eruptions,
such as urticaria,
- Musculoskeletal system should include inspection and/or
palpation of effusions, assessment of range of motion
and assessment of muscle strength and tone for connective
tissue diseases.
Eye, Nose, and Throat (ENT)
- Under constitutional, vital signs are listed as being
required in a complete examination. Rarely, is it necessary
for ENT patients to have vital signs registered except on
a pre-op physical exam. Blood pressure is a significant
issue in people with balance problems but rarely are other
vital signs necessary for examination and treatment of otolaryngologic
patients.
- There is little necessity to document the condition of
the orbit in most instances.
- Under ear, nose, mouth and throat, assessment of hearing
with tuning forks and clinical speech reception thresholds
is a requirement for a comprehensive ENT exam. Many people
are unable to cooperate with tuning fork testing because
of age (children) or a mental condition (elderly and developmentally
disabled). One ENT specialist states that:
"clinical speech reception thresholds
have been tested and found to be filled with air even in
the best testing situation. Clinical speech reception thresholds
without making note of ambient noise levels are worthless,
and that requirement should be removed without question
as a necessity for comprehensive examination."
- The respiratory system, i.e. the lungs, is not a necessary
part of a comprehensive otolaryngologic examination. Most
ENT problems do not involve the tracheal bronchial tree
and to require that these be included in such an examination
is unnecessary. One member commented that ENT specialists
listen to lung sounds occasionally and evaluate respiratory
effort and such that it should not be a standard procedure
on all comprehensive examinations.
- The inclusion of a cardiovascular in a complete otolaryngologic
examination is not necessary. Outside of blood pressure
and perhaps the examination of pulse rate in patients who
are dizzy and vertiginous, there is almost never an indication
for cardiovascular examination in an otolaryngologic exam.
- Under the ENMT exam, the clinical speech reception thresholds
assessment is an inaccurate and unreliable measure of hearing
acuity. It gives no more information than the "general
observation of ability to communicate" listed under
the Constitutional examination. This element should be deleted.
- Auscultation of the lungs under the Respiratory system
and auscultation of the heart under the Cardiovascular system
both require partial disrobing of the patient. Otolaryngology
offices are not set up with either facilities or appropriate
chaperones for this to occur. Neither exam is directly germane
to the head and neck examination.
- Under the Cardiovascular system, examination of the peripheral
vascular system should be replaced with detection of bruits
in the neck.
- Under the Lymphatic system, examination should be limited
to the neck. Examination of the axilla and groin requires
partial disrobing of the patient and is not germane to the
head and neck examination.
Neurological
- The format for neurological examinations is not that usually
used by neurologists, nor is it particularly logical.
- There is no credit given for a physician who:
- examines the axial skeleton for tenderness and general
mobility;
- palpate or percuss peripheral nerves, seeking evidence
of enlargement or irritability at sites of entrapment or
compression;
- searches for "tension signs" indicating lumbar
disc herniation.
- Mood and affect should be deleted, since it has no relevance.
- Add detailed examination panels based upon the specific
disease or symptom (such as dizziness) which would include
a detailed in-depth analysis using tests such as:
- Hallpike maneuver
- Sharpened Romberg
- Fukada stepping test
- Dynamic visual acuity
- Head thrust maneuver
- Consider requiring a cardiovascular system exam ONLY on
patients at risk for stroke.
- Add several additional systems that are more relevant
to the specialty, and require that at least one of these
be examined in order to bill for a comprehensive level neurological
examination. These additional systems include: skin, meningeal
signs, axial skeleton, tension signs of lumbar disc herniation,
palpation and percussion of peripheral nerves.
A professor and vice chairman of neurology comments that:
"...As the requirements now stand, I could
see a patient with suspected neurofibromatosis, carefully
examine their skin surface looking for the cutaneous stigmata
of that disease, do straight leg raising tests on both legs
looking for signs of nerve root irritation, percuss and palpate
the entire spine searching for tenderness, deformity and evidence
of scoliosis, examine the tympanic membranes and outer ears
because of hearing related complaints, and examine the neck
for meningeal signs, yet get credit for doing none of this.
In fact, I would be "downgraded" if I happened not
to examine the carotid arteries, heart and peripheral vascular
system, all unlikely to be pertinent in the hypothetical patient..."
Another neurologist comments that:
"...There is no way to receive credit for
evaluation of any cognitive functions related to the right
brain (e.g. visuospatial function, neglect syndrome, or the
frontal lobes), or any neuropsychiatric manifestations..."
General Multi-System Exam
Many of our members have provided general comments for changing
the multi-system exam requirements. These are summarized below.
However, we are also attaching specific comments for changes
recommended by a group of trauma surgeons.
1. Cardiovascular
- Add an element for "jugular venous distension, hepatojugular
reflux".
2. Gastrointestinal (Abdomen)
- Add an element for auscultation of bowel sounds. This
is a separate exam element and requires a distinct performance
by the physician. It is commonly performed and requires
separate identification.
- - Add "contour and consistency of abdominal wall"
as an element.
3. Chest
- -Add inspection and palpation of breasts as it appears
in the genitourinary exam.
4. Musculoskeletal
- - Re-organize the required elements into three categories:
- 1. Inspection/palpation
- 2. Assessment of range of motion
- 3. Assessment of the stability and alignment performed
on ANY of the following joints:
- --cervical spine
- --lumbar spine
- --both shoulders
- --both elbows
- --both wrists
- --all finger joints of both hands
- --both hips
- --both knees
- --both ankles
- --all toe joints of both feet
- - Drop all other requirements.
- - Establish a new number of required elements to perform
from this system.
5. Neurological
- - Add cerebellar testing.
6. Skin
- - Add inspection of nails.
Additional Miscellaneous Comments on the Multi-system
Exam Requirements
- A radiation oncologist comments that neither the general
multi-system nor the specialty specific exams cover the
type of examination required by the oncology patient and
performed by the radiation oncologist. For example, a head
and neck patient may require a detailed ENT examination;
however, he/she may not require pneumotoscopy or an assessment
of hearing. In addition, the patient may require many, but
not all, the elements of the general multi-system exam.
Therefore, the radiation oncologist will never be able to
bill a comprehensive level of care unless he/she performs
elements of the examination that are not medically necessary.
- Further, malignant melanoma patients require a comprehensive
skin and lymphatic exam as well as parts of the general,
multi-system exam. None of the single specialty examinations
or the general medical exam contains all the appropriate
elements. This would support our recommendation for the
creation of one master list of elements and for a cafeteria
approach to meeting the total number of required elements
to be performed and documented by a physician.
- Accommodation should not be examined in most patients
since the reflex is lost during young adulthood.
- Assessment of hearing should be gross.
- Examination of the nasal mucosa, septum and turbinates
seems extreme for a general multi examination.
- Examination of the thyroid is rarely useful if there is
nothing in the history or remainder of the examination to
make one suspicious. It should be dropped as a requirement.
- Percussion of the chest is obsolete and it's impact on
clinical outcome has never been well documented.
- Examination of the carotid arteries, abdominal aorta,
and femoral arteries are age specific.
- Examination of the female bladder seems odd, the pelvic
examination is usually done with an empty bladder and the
bladder is rarely if ever actually palpable. One should
certainly comment upon tenderness anterior to the vagina
and uterus but whether this is tenderness in the bladder
or not is very difficult to tell for certain without further
studies.
4. Compliance/Audit Concerns
Although the guidelines increase the physician work required
to bill at all levels of service, in particular levels 4 and
5, teaching physicians have become skeptical regarding their
ability to document accurately the extent of their personal
service to the patient. Their concern is legitimate and a
direct result of current audit activities under the PATH initiative,
daunting institutional compliance policies, and uncertainty
as to how the service of the resident interacts with their
personal service. In some departments, such as the emergency
department, the sheer volume of patients treated in one shift
places real constraints on the physician's time available
to document any one visit service. At many institutions, the
clinical faculty have agreed to automatically down-code the
service performed by one level to assure compliance with the
guidelines in the event of a carrier audit. In academic clinical
departments that are already in financial distress, this action
results in income lost and for some localities, could seriously
impact the viability of the service and constrain access.
To reassure physicians, HCFA should adopt a carrier audit
policy that permits an error of one level difference (higher
or lower), without penalty, in the visit code billed that
is deemed higher than that which the auditor believes is substantiated
by the documentation. This policy is reasonable and justifiable
in light of the demonstrated subjectivity of the two processes
involved: the selection of the service level by the physician
and the determination of the appropriateness of that level
by the auditor. Both processes are prone to error because
of the nature and complexity of the EM coding architecture.
Perhaps the most poignant comments of our members touch upon
the current state of mistrust between government and the medical
community. Our members comment that the most offensive aspect
of the guidelines is that they send a message that suggests
physicians, collectively and individually, are neither ethical
nor should they be trusted. A faculty physician wrote:
"...We must protest the atmosphere of distrust
that is being created and into which this coding and
documentation system is being injected. Responsible physicians
are as concerned as the government about the small minority
of physicians who may be abusing the system. However,
remedies for this isolated aberrant behavior must reflect
the true nature and extent of the problem. You (government)
cannot distort the processes of care or inject elements
of distrust or fear of reprisal without degrading the
therapeutic nature of the doctor-patient relationship..."
We share our members concerns and hope to work with HCFA
and the AMA in addressing these issues.
The AAMC wishes to thank the AMA CPT Editorial Panel staff
for coordinating this effort to revise and improve the guidelines.
We also wish to commend HCFA for agreeing to participate fully
in the process. Should you have questions regarding these
comments, kindly contact Robert D'Antuono, Assistant Vice
President, Division of Health Care Affairs at 202-828-0493.
Sincerely,
Jordan J. Cohen, M.D. President
cc:
Richard Knapp, Ph.D.
Robert Dickler
Celeste Kirschner
Catherine Scally
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