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Letter to Berenson, Dickey, and Harris

July 22, 1998

Robert A. Berenson, MD
Director Center for Health Plans and Providers
Health Care Financing Administration
7500 Security Blvd.
Mail Stop C5-24-06
Baltimore, MD 21244-1850

Nancy W. Dickey, 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

Dear Colleagues:

The Association of American Medical Colleges (AAMC) appreciates the opportunity to provide comments on the current draft framework for the Evaluation and Management Documentation Guidelines. AAMC staff and constituents are encouraged by the substantially improved draft circulated April 27 and strongly support the proposed revisions, with some modifications. We hope that these additional comments will help identify further refinements that the American Medical Association (AMA) will endorse, and the Health Care Financing Administration (HCFA) will include, in the final document.

In our comment letter of April 13, the AAMC summarized the suggestions received from nearly 100 teaching physicians representing over 50 of the 125 medical schools across the country. Many of our comments are focused on ways to simplify the current system, in particular, the format and definitions for the types of history, exam and medical decision-making.

Compliance Requirements vs. Documentation Guidelines

The AAMC membership supports the AMA House of Delegates resolution to eliminate all numeric references and requirements from the final documentation guidelines. The AAMC is equally concerned with the need to have payment rules that embrace both reasonable documentation standards as well as reasonable audit criteria. Therefore, if the guidelines are to serve two purposes---one as a carrier audit tool, and another as a guide to assist physicians in improving their documentation to substantiate a level of service billed, then a system that includes some numeric reference points within selected types of care components for the history and the exam may be a reasonable compromise. Medical decision-making does not presently include numeric requirements. We have provided our recommended numeric requirements in the discussion of history and exam below.

It is important too that HCFA couple these changes with an audit policy that allows a one level difference in the coding submitted for a service, for both pre-payment and post-payment audits, without double or treble penalties applied. This is one way that HCFA can reassure physicians who are concerned about being unfairly penalized for subjective interpretation of their documentation.

Finally, the AAMC membership believes that more fundamental changes to the EM coding levels and architecture are necessary---if not now, then over the course of the next three years during the update process to complete the fifth edition of Current Procedure Terminology (CPT-5). Since changes to the EM service levels and definitions is likely to require changes in the relative value units assigned to these service codes, we believe HCFA should model the impact any change in service codes would have on payments to better assess the benefits relative to the costs of such service code changes.

The AAMC appreciates being included as a participant in this important update process. We believe that many significant and beneficial refinements can be made to improve the system with relative ease, reduce the administrative burden to physicians and redirect physician time back to professional activities that truly benefit patients and their families.

If HCFA determines that it wishes to proceed with the current system, our recommendations are as follows:

History

Clarify chief complaint. In order to add clarity to the guidelines, the AAMC recommends that the instruction for chief complaint be edited to include the following:

Document the chief complaint and/or the reason for the encounter for all codes except those that require an interval history, for example, inpatient hospital services.

Combine the history of present illness (HPI) and review of systems (ROS) activities. Our members continue to state that there should not be an artificial distinction between these fact- gathering activities in CPT. We would also urge HCFA to begin to recognize that the adequacy of a physician's documentation should not be based solely on achieving or exceeding a numeric "count" of required items documented in a note. While it is apparent that a fundamental goal of the guidelines is to provide carrier and OIG auditors with an objective method by which to evaluate claims, physicians should still have the flexibility and prerogative to document only the appropriate history of facts and medical conditions most relevant to a patient's care. To require otherwise serves only to redirect physician time and resources away from direct patient care activities that improve the health and satisfaction of the beneficiary to administrative tasks that offer no added value to the care process. Emergency medicine is a good case in point. Emergency medicine physicians, in particular, can not practice efficiently under a rigid payment scheme that requires a fixed number of elements to be documented for history or exam. Such a construct is simply not relevant to the emergent care process.

In absence of some more fundamental consolidation and simplification of these history types, the AAMC recommends that the HPI and ROS be combined in the draft matrix on page 4 of the working document and defined as follows:

Notice the change in verbiage from "most relevant" to "the relevant" to "all the relevant" for the various levels of HPI and ROS requirements. The subtle change in phrasing implies a scaled approach without stating a specific number for these activities. The phrasing communicates an instruction that more documentation is required as a physician moves up the scale and provides a higher level of care, yet avoids the offensive numeric instructions. HCFA should recognize that a desired behavior may be communicated in various ways to a targeted audience. The above phrasing, we believe, will achieve the desired response from physicians and provide carriers with adequate direction to audit claims appropriately.

Lastly, we recommend that for subsequent inpatient or outpatient visits a notation of "no change from previous ROS" should not be required and that no reference to the ROS in a follow-up note should automatically imply "no change" in status. Again, if it is not clinically relevant to write a comment, the physician should not be required to write a comment. The same recommendation applies to the PFSH.

Again, the AAMC believes that further consolidation of these history types---perhaps into three types defined as "brief, extended and complete" would simplify the process. Each type could be consistently defined as much as possible throughout the EM coding system without major change to the assigned relative values. Using consistent terminology for all three care components of the visit service would make the system far more user friendly. Minor changes such as this serve to minimize confusion among physicians, ease the audit process, and simplify the system significantly.

Past, family, and/or social history (PFSH).

The AAMC believes that physicians do not need two levels of PFSH to adequately assess and document this activity of the history. We recommend that HCFA define one type---a "pertinent" PFSH--- and allow physicians the flexibility to document the extent of the PFSH across the all categories in the most appropriate manner for the patient. We recommend that the Pertinent PFSH be defined as follows:

As recommended above under ROS, a notation of "no change in the PFSH" should not be required for subsequent inpatient or outpatient visits. One member writes that "...On the 32nd daily inpatient visit to a burn victim or a patient with chronic respiratory failure, it is exceedingly tedious (and clinically meaningless) to write once again ‘PFSH no change from information recorded in the progress notes on March 7, 1998'..."

Define all types for an interval history.The interval history as opposed to an initial history, is used frequently for documenting subsequent hospital care, home visits, and nursing facility care. There are no criteria currently for interval history. The AAMC recommends that HCFA define the criteria for differentiating among the types of an interval history. Also, the final guidelines should include a reference that an interval history does not require the documentation of past, family and/or social history.

Examination

Eliminate or minimize the number of required elements for the types of exam. The AAMC believes that the draft policy creates another unnecessary impediment for physicians striving to optimize their time with patients and to perform their work efficiently. The numeric requirements in the draft are excessive and should be eliminated entirely for the lower level exam types and minimized for the higher level exam types.

If a policy of one uniform count of total elements for ALL exams is adopted, then the AAMC recommends that the requirements for both the multi-system and single organ system (area) exams be revised as follows:

Clarify examination instructions. The revised instructions for the examination should specify if ALL areas, versus SELECTED areas, must be examined and documented when a particular item has multiple areas to examine. For example, in the integumentary exam, it is unclear if the physician must inspect and/or palpate all three areas---genitalia, groin, and buttocks? Is the physician permitted to select among any one area to examine, as relevant to the patient? We recommend that the instruction require "one or more areas to be examined and documented," depending upon the relevancy to the patient.

Another example is in the musculoskeletal system exam. Our members recommend that the instructions clearly state that for each of the items listed for an extremity exam (leg or arm), "one or more areas be examined and documented" again depending upon relevancy to the patient. HCFA should also state clearly that each joint, for example, right ankle plus left ankle, equals two elements examined and not one element. Other changes to simplify the musculoskeletal system exam were suggested previously in our April 13 comment letter. Our members continue to state that this particular organ system exam is confusing and needs a substantially revised format.

We note that the first draft guidelines gave credit for the inspection, palpation, ROM/stability, muscle strength/tone of separate elements for each joint and then within each joint, so that the examination of a single joint could result in four elements rather than just one element credited. The second draft confuses this instruction and infers that only one element would be allowed regardless of how extensively the joint was examined. This type of confusion illustrates how problematic it is to attempt to convert EM documentation to a numeric process. For this specialty exam, the AAMC believes that HCFA should allow separate credit for each joint and each activity performed within each joint.

The AAMC also recommended in our letter of April 13 that specialty exams be added for pediatrics, obstetrics/gynecology, and rehabilitation medicine. Please refer to that letter for suggestions on additional exam elements.

Medical Decision-Making

The AAMC strongly supports the revised guideline that would allow selection of the type of medical decision-making (MDM) to be based upon "the highest level in any one column". Further, we fully support consolidating straightforward complexity into the low complexity type and strongly support the proposed revisions. However, MDM remains problematic for our members. For example, our members believe that medical decision-making for emergency medicine physicians should be based upon the chief complaint given that the nature of care in this setting does not typically allow adequate time for many ancillary tests and other clinical interventions to be performed and reviewed prior to treatment by the physician. The propensity to apply quantifiable conditions to a highly subjective process benefits only the carrier or OIG auditor and is perceived as arbitrary, intrusive and clinically meaningless physicians doing the medical decision-making.

Therefore, the AAMC continues to emphasize a few general points about the MDM construct:

• Improve and edit the descriptions for each type of MDM. The descriptions for each type of medical decision-making (ie. number of diagnoses, risk of complications, complexity of medical records and data reviewed, management options, etc.) need to be better illustrated and defined. For example, we recommend that the following activities be added to the MDM table:
  • Under "high" MDM add to column 2: Review and/or summarization of old records; and/or obtaining history from a source, such as a provider other than the patient; and/or discussion of case with another health care provider requiring at least 20 minutes of physician time.
  • Under "high" MDM add to column 2: Review and evaluation of image(s), tracing(s) or actual specimen(s) requiring at least 15 minutes of physician time.
  • Under "high" MDM add to column 3: Management of a therapeutic drug regimen with a high risk of toxicity that necessitates extensive, ongoing monitoring by a physician. For example, methotrexate, cytoxan, immuran and cyclosporin.
  • Under "moderate" MDM add to column 2: Review of reports from diagnostic or interventional radiology/pathology/or other diagnostic test results requiring at least 10 minutes of physician time.
• Consider adding a severity "proxy" to aid physician selection. In addition to refined descriptions for each MDM type, members have suggested investigating the use of ICD-9-CM codes, DRGs, chief complaint, or some acceptable patient severity index as a "proxy" to assess the intensity of a physician's medical decision-making. For example, certain commonly used diagnostic codes or DRG's could be included in the MDM grid to illustrate patient severity. It would be presumed that the more severely ill the patient, the more intense the MDM activities of the physician. Lastly, the clinical vignettes in CPT could be classified by MDM level and incorporated in the table as illustrations.

Counseling and Coordination of Care

Coordination of care activities are an important and time-consuming activity for many specialists, especially those practicing in academic settings. These services are of great value to the patient, yet the current policy for counseling and/or coordination does not address adequately the work performed by physicians to coordinate the care of patients. We believe that CPT should provide a definition of both counseling and coordination of care activities.

As it stands, counseling and/or coordination activities must occur either "face-to-face" or on the "floor/unit" with the patient. This may be appropriate for counseling services, with the patient and/or family members, but it is completely inappropriate when the activities of the physician involve coordination of care among multiple providers and other physicians. In situations where the patient is uncommunicative, for example in end-of-life situations, counseling and coordination of care is directed to the closest family members. This time should be included in the definition of these care activities.

Our members state that coordination of care frequently involves lengthy review of medical records, discussions of findings and potential therapies with the radiologist, pathologist, other consulting specialists, non-physician providers, etc., in order to develop an appropriate care plan for a complex acute or chronically ill patient. Further, the AAMC believes that these activities are not recognized among the activities of medical decision-making in a way that allows appropriate billing by the physician under either the routine EM codes, or under the counseling and coordination payment policies.

To illustrate for codes requiring all three key components: A physician receives no credit for the time spent in these activities when incorporated into the MDM process, unless the highest level of history and exam is performed as well. Similarly, for established patients the physician work is not adequately recognized. For example, for an outpatient visit on an established patient, if a physician's MDM is high for a particular visit, yet the history and exam performed is only expanded (since presumably a more comprehensive history and exam were performed on the patient's first visit), the physician would be allowed only to select a level 3 code--99213. Although CPT would require the physician to use a counseling and coordination code for any visit service where 50% of the time is spent on coordination of care, the current payment policy excludes de facto the significant amount of work performed by a physician if the care coordinating activities are not performed either "face to face" or "on the floor/unit" with the patient. Location should not be the determinant for payment of coordination of care activities.

The AAMC strongly recommends that coordination of care be defined and that the policy be changed to allow payment of coordination of care activities (as intended), as illustrated above, on a time basis when performed by the physician under any of the following conditions: 1) face to face with the patient; 2) on the floor or unit of the patient; or 3) in another department or location of the facility, such as, pathology, radiology, library, consultation room, etc. for a portion of, or for the entire duration of, the coordinating activities. Time spent in counseling the patient and engaged in coordination of care activities are then combined to choose a level of service.

While the AAMC recognizes that some of the above activities are included in MDM, we believe that they are undervalued. Reiterating these activities within the context of counseling and coordination of care services will go a long way toward addressing one of the major concerns expressed by physicians, ie. the MDM process is not adequately recognized for payment purposes by HCFA.

One final clarification to the draft guidelines is recommended. The reference on page 15 to "office or other outpatient and hospital or nursing facility" should be deleted or prefaced with "for example" so that the provider does not think the instructions apply only to these codes.

General Documentation Instructions

Documentation of services to special populations. We note that the revised draft does not include the special instructions for patient populations other than the typical adult population. The final documentation guidelines should explicitly state that HCFA will allow variation in the documentation requirements for history and exam activities performed on infants, children, adolescents, pregnant women, patients who cannot communicate, or other special patient groups. Further, the AAMC believes that HCFA should provide instructions stating the physician may render and be paid for a higher level of service to these populations without meeting all the usual requirements specified for the typical adult patient population.

Documentation of preventive medicine services. Although Medicare does not cover prevention services (99281-99397) currently, the Medicaid program and other insurers do. Therefore, the guidelines should include special instructions for the documentation of these services. Specifically, the guidelines should acknowledge that preventive medicine services are inherently different from other visit services and state that the content of a preventive medicine exam is based on age and risk factors and that the content requirements (i.e. the number of exam elements required for a comprehensive level multi-system exam) should not apply to preventive medicine services. The same issue applies to history. The guidelines should state that the comprehensive history obtained as part of the preventive medicine evaluation is not problem oriented and does not involve a chief complaint or history of present illness (see page 7 of CPT manual for comprehensive language). Also to add clarity, the guidelines should explicitly state that these definitions supersede the typical definitions for comprehensive history and exam when done as part of a preventive medicine evaluation. Special Instructions for Teaching Physicians

Lastly, the AAMC recommended in our April 13 letter that the final documentation guidelines include a section specifying the instructions for teaching physicians. In our April 13 letter, we provided specific language for these instructions. We again suggest that these be included in the final document. HCFA should also consider the following summary of the teaching physician documentation instructions:

Given that Medicare rules permit a teaching physician (TP) to substantiate a charge based on the combination of the resident's and teaching physician's notes, the teaching physician's note must 1) clearly convey that he/she saw the patient; and 2) participated in the visit service consistent with the level of service billed. In addition to establishing presence with the patient ("patient seen" or "patient seen and examined"), the TP should document the most important patient-specific elements for each of the required key component of the visit services, i.e. summarize the history, exam, and medical decision-making, and refer to the resident's note for the remaining details of the visit service.

New patients, hospital admission work-ups, consultations and emergency room visits require all three items. The teaching physician's note must clearly convey that if he/she performed an exam, documenting the extent of the exam to support the level of service billed. For example, in order to bill a level four consultation or new patient visit, CPT requires a comprehensive history, comprehensive exam and medical decision making of moderate complexity. Therefore, the teaching physician must either observe the resident perform a comprehensive exam, or personally perform a comprehensive exam in order to bill a level four service. Regarding history and medical decision-making, the teaching physician must also document the history of present illness and key aspects of his/her medical decision-making (eg. plan of care including diagnostic tests, drugs, and other therapies). The level of history and medical decision-making will be determined by the combined note of the teaching physician and the resident.

A template may be used to organize the teaching physician's personal documentation. The following template illustrates an acceptable approach to teaching physician documentation:

Resident's history reviewed, patient interviewed and examined. Briefly, history is as follows[...]

On exam I find [...] OR My exam confirms all of the resident's findings of note (summarize exam) [...] OR I was present during the resident's exam of note and confirm [...]

Assessment and plan of care reviewed with resident. I agree. Lab and other tests show [...] differential DX is [...] Plan is to [...] See resident's note for complete details.

The AAMC wishes to thank the AMA and HCFA for the opportunity to participate in this process and to provide these comments. 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:
Aaron Primack, M.D., HCFA
Jean Harris, HCFA
Catherine Scally, HCFA
Mark Segal, Ph.D., AMA
Celeste Kirschner, AMA
Douglas Henley, M.D., AMA CPT-5 Project Advisory Group
Karen Borman, M.D., AMA CPT-5 Project Advisory Group
William Gee, M.D., AMA CPT-5 Project Advisory Group
Council of Academic Societies (CAS)--Government Relations Representative
Group on Faculty Practice Steering Committee
Richard Knapp, Ph.D.
Robert Dickler