Medicare's Coding System
for Evaluation and Management (EM) Services and Documentation
Guidelines
 |
|
|
Related Resources
AAMC Documents
|
|
Background
Evaluation and management (EM) services refer to visits and
consultations provided by physicians or residents under their
supervision. Each of these services is assigned a CPT (Current
Procedure Terminology) code for billing purposes. These codes
were developed by the American
Medical Association and implemented by HCFA
in 1992, as part of the sweeping changed required by the resource-based
Medicare fee schedule payment system. Like all CPT codes,
EM codes are "universal" and used by Medicare, Medicaid
and most other payors for processing claims for the professional
services of physicians. Since visit and consultation services
are high volume physician activities, the EM codes are the
most frequently used by physicians in daily practice.
How Physicians use EM Codes
To bill for a patient visit conducted at a clinic, office,
hospital, emergency department or nursing home setting, a
physician must select an EM code that best represents the
service performed. EM codes are organized into various categories
by delivery site of service, then into as many as five discrete
"levels" or "established" patients. All
these categories and code levels are intended to provide the
physician with an opportunity to select the code that best
reflects the extent of his/her personal work necessary to
perform the visit service.
EM services are constructed on the basis of physician performance
in three "key" elements of every visit or consultation
service: patient history, examination and medical decision-making.
In a teaching setting, the physician must either personally
perform or observe a resident perform the key elements of
the visit service. Secondary factors for selecting a code
include the activities of counseling, coordination of care,
nature of the problem and the time spent "face to face"
with the patient. As the degree of physician involvement and
work intensity varies along the key components of history,
exam and medical decision-making for any visit service performed,
so does the level of code selected. The more work performed
by the physician, the higher the level of code he/she may
bill within the appropriate category.
Medicare carriers were advised by the HCFA national office to
provide focused educational programs for practicing physicians
to assure that physicians understand and use the codes properly.
An Example of EM Coding
A cardiologist sees a new patient for a cardiology consultation
in an outpatient clinic setting. To bill the cardiologist
must select EM code category 99241 to 99245, and then select
the appropriate service from one of the category's five levels.
To determine the appropriate EM code, the physician must make
a judgement about the patient's condition for each key element
of service--patient history, examination, and medical decision-making.
Then, the physician must make more judgements about the nature
and extent of work he/she provided. In detail, the EM coding
processes includes determining the levels of service through
several steps:
- Step one: Determine the Level of History. History consists
of the review of present illness, review of all organ systems,
review of past medical, family and social history, and the
assessment of an array of physiological factors within each
of the areas of history, including a review of eight elements
of history and 12 to 14 organ systems.
- Step two: Determine the Level of the Physical Exam. For
the required multi-organ system examination, the physician
is permitted to use clinical judgement relative to the nature
of the patient's problem(s) and as to what extent all 12
organ systems should be examined. Once the physician has
conducted the exam, he/she must decide whether the exam
was problem focused, expanded problem focused, detailed
or comprehensive.
- Step three: Determine the Level of Medical Decision-Making.
Medical decision-making refers to how the physician rates
his/her degree of difficulty in establishing a diagnosis
and treatment plan for the patient. The levels of EM services
recognize four types of medical decision-making--straight
forward, low complexity, moderate complexity and high complexity.
Identifying the appropriate type requires another three
layers of decisions to determine:
- a) the number of diagnoses or care options rated as
either minimal, limited, multiple or extensive.
- b) the amount and/or complexity of date to be reviewed
as either minimal, limited, moderate or extensive.
- c) the risk of complications and/or morbidity, mortality
as either minimal, low, moderate, or high in accordance
with the assessment of the nature of the patient's presenting
problems, diagnostic procedures ordered and management
options.
- Step four: Aggregate All Determinations and Select a Level.
If, for example, the cardiologist performed a comprehensive
history, a comprehensive exam, and a medical decision making
with a high complexity, than he/she would be able to bill
a 99245, the highest level consultation code.
The AAMC is concerned that the current EM coding and documentation
system is not well coordinated with Medicare's final rule
for teaching physicians, implemented in July, 1996. The AAMC
believes that a teaching physician's efforts to deliver patient
care and train residents, should take precedence over elaborate
and burdensome payor requirements for billing. Therefore,
the AAMC advocates that HCFA work to streamline the EM coding
system and coordinate the general guidelines for selecting
and documenting EM services with the Carrier Manual Instructions
for the 1996 Medicare rule for teaching physicians.
EM Documentation Guidelines
Currently, HCFA and the AMC CPT Editorial Panel have begun
a process to review, refine, and change the original EM Documentation
Guidelines that were published by HCFA in May, 1997. Scheduled
to go into effect on July 1, 1998, the medical community was
invited to submit comments on the guidelines prior to an April
27 briefing session to be held in Chicago and hosted by HCFA
and the AMA. The AAMC completed and forwarded a lengthy critique
and comprehensive recommendations for improving the guidelines
based on comments received from AAMC members in March. (Comment
letter dated April 13, 1998 to Dr.'s McCann, Wooton and Harris
and Comment letter dated July 22, 1998 to Dr.'s Berenson,
Dickey and Harris)
As a result of the fly-in, the AMA and HCFA agreed to delay
implementation of the guidelines until no sooner than the
spring of 1999. In addition, a revised framework for the EM
documentation guidelines was circulated for comment. The revised
framework is a significant improvement over the original document
issued May, 1997. Since the April 27 briefing, the AMA House
of Delegates voted to reject the revised framework and the
"numeric" approach for Medicare documentation. (Washington
Highlights article April 30, 1998, HCFA Adopts AAMC Suggestions
to Delay Implementation and to Revise Documentation Guidelines.)
Congressional Activity
A resolution has been introduced into both the House and
Senate on the subject of excessive documentation requirements
(H. Con. Res. 264 and S. Con. Res. 93). Rep. Frank Pallone
(D-N.J.) introduced the House resolution on April 28, 1998
and Sen. Robert Torricelli (D-N.J.) introduced the Senate
version on May 4, 1998.
AAMC Action
AAMC staff have forwarded two lengthy comments letters--one
on the original EM documentation
guidelines and a second on the
revised framework published in April 1998 to both HCFA,
the AMA and to all major specialty societies. In addition,
AAMC staff have had a series of meetings with high level HCFA
officials to discuss our recommendations for improving and
simplifying the guidelines. The AAMC advocates pilot testing
the guidelines in at least one academic medical center prior
to implementation.
Contacts
Denise Dodero, Associate Vice President
AAMC Health Care Affairs
ddodero@aamc.org
(202) 828-0493
This page contains documents in Portable Document Format (PDF).
The Adobe Acrobat® Reader® is required to view PDF documents. Download
Acrobat® Reader®.
|
