Revisions to the 1995 and
1997 E & M Documentation Guidelines
Background
In June 2000, HCFA, now the Centers for Medicare and Medicaid
Services (CMS), held a town hall meeting at which they distributed
draft Evaluation and Management Documentation
Guidelines (PDF, 2 pages - 10 KB). The guidelines
were subsequently revised in December 2000. The guidelines
focused on correct documentation of E&M encounters with
Medicare beneficiaries and offered an alternative approach
to the guidelines released in 1995 and 1997 through the use
of clinical examples designed to enhance the interpretation
and understanding of the new guidelines. CMS contracted with
Aspen Systems Corporation to develop these clinical examples,
which were specifically intended to illustrate the guidelines
for various levels of physical examination and medical decision-making.
Clinical examples were developed for 16 medical specialties.
In May 2001 Aspen introduced their methods for developing
the clinical examples, as well as the examples themselves,
in order to begin an in depth 60 day review by physicians
representing organized medicine and Carrier Medical Directors.
According to the AMA, "at the time of the introduction,
specialty societies had many questions regarding how the clinical
examples would be used in practice, the availability of Carrier
feedback to the specialties, coordination between Carriers
and specialty societies, and next steps. Also, the possibility
that the clinical examples were based on medical records that
were "downcoded" was raised as a serious concern".
AMA held a specialty society meeting designed to collect
broad specialty society reaction to the CMS/Aspen clinical
examples. Subsequently, a letter was sent to Thomas Scully,
Administrator of CMS. The letter focused on the Bush Administration's
efforts to reduce the regulatory burden on physicians and
called on CMS to re-examine the need for documentation guidelines
and their commitment to the development of clinical examples.
The letter made the point that it would be more appropriate
for organized medicine to develop their own examples that
accurately reflect appropriate levels of patient care, rather
than use those suggested by Aspen.
In July 2001, the Department of Health and Human Services
responded by indicating that they were willing to address
the burden of E&M documentation. CMS and Aspen stopped
activities related to the 2000 Documentation Guidelines clinical
examples and stated their intention to initiate a CMS task
force to examine the issue. CMS later indicated that they
believed that E&M coding should also be reviewed and it
was their belief that physicians may be having problems with
the E&M descriptors and CPT coding guidelines.
Current
The AMA, through its CPT Editorial Panel, is responsible
for maintaining CPT codes. AMA indicated that a "preferred
approach would be to address ambiguities with the code descriptors
and coding guidelines through the established CPT Panel process.
The Panel opted to form an E&M Workgroup to address CMS's
concerns. The Federal Advisory Committee Act (FACA) prevented
CMS from organizing its own task force and the Panel's Workgroup
provides a viable approach to resolve CMS's coding concerns.
CMS supports the E&M Workgroup and will participate in
its deliberations."
In November 2001 the AMA moved this issue further along through
its CPT Annual Advisory Committee and Editorial Panel Meeting,
at which the issue of a Panel E&M Workgroup was discussed.
Subsequently, the Panel voted unanimously to form a Workgroup
that would report back to the Panel in November 2002.
The Panel E&M Workgroup includes representatives from
several specialties, CMS, Practicing Physicians Advisory Council
(PPAC), a Carrier Medical Director, the Blue Cross Blue Shield
Association and the AMA Board Ad Hoc Task Force on E&M
Documentation Guidelines. The charge of the Workgroup is to
"enhance the functionality and utility of CPT Evaluation
and Management (E&M) codes by recommending changes in
code descriptors, codes selection criteria and/or code levels
in order to improve understanding among physicians and payors.
E&M codes must reflect current clinical practice and continue
to describe physician work, while reducing the need for documentation
guidelines and ensuring that any remaining documentation guidelines
are oriented toward facilitating patient care." The workgroup
has stated that it will collect data through physician surveys
and oral and written testimony, and will perform analyses
of existing and alternative coding structures.
The E&M Workgroup held it's first meeting on Friday,
January 18 and will meet monthly through the first half of
the year.
According to AMA, the first meeting focused on the following
items and issues:
- review of the charge from the Panel to the Workgroup;
- history of the current E&M codes, documentation guidelines
and CMS audit practices;
- examination of the flaws of the current codes;
- review of the needs of physicians and payors for E&M
coding;
- development of Workgroup mission and vision statements,
as well as principles for E&M coding and for code revisions;
- brainstorming on preliminary options to meet needs and
correct problems;
- discussion of Workgroup data needs and analysis/collection
methods.
The E&M Workgroup Meeting II was held on Friday, February
15. According to AMA, the meeting focused on the following
items and issues:
- discussion and fine-tuning of the mission statement, which
reads as follows: Develop a coding system that physicians
can use to report their services while practicing medicine
according to the needs of the patient.
- reviewed CMS frequency data trends and actual analysis
- discussion of Health Economic Research Report on validation
of physician time data
- reviewed the concept of total physician work and different
approaches to define and incorporate it with visit codes
- discussion of time, medical decision making and the relationship
between them
- refinement of research plan; identified the need to conduct
a survey, as well as the need for Specialty Societies to
provide input.
The Practicing Physicians Advisory Council (PPACO) discussed
this topic at its March 2002 meeting and learned that the
workgroup expects to release its recommendations to the physician
community after its August 2002 meeting and hopes to conclude
its work by February 2003. Also, according to Douglas Wood,
M.D., chair of the workgroup and a cardiologist from Mayo,
the workgroup recognizes that any revisions to the existing
evaluation and management services codes would have an impact
on many different specialty groups, the Workgroup outlined
the following principles for use while developing options
for resolving issues related to the use of the existing E&M
codes:
- the system should be easy to understand and use by physicians,
payers and beneficiaries;
- definitions of codes should be clinically meaningful
and describe clearly-differentiated services;
- there should be consistency between code families;
- choice of a code should be simple, and should reflect
the total physician work;
- the system should allow physicians maximum flexibility
in demonstrating the level of work involved in a service;
- physicians should not suffer a reduction in reimbursement
from implementation of an improved and simplified coding
system for evaluation and management services;
- the code set should reflect contemporary medical practice;
Dr. Wood also informed PPAC that the Workgroup is in the
process of developing a survey instrument for a random sample
survey of 500 physician practices. The survey will attempt
to gather information about how E&M codes are selected,
whether the respondent believes the E&M codes and instructions
are clear and easy to use and the extent to which the current
codes accurately reflect the care provided to a patient in
an office visit.
The Workgroup is also planning on holding a daylong conference
in which specialty societies will be invited to respond to
questions. The conference will be held on Friday, May 17.
Contact
Denise Dodero, Associate Vice President
AAMC Health Care Affairs
ddodero@aamc.org
(202) 828-0493
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