Will We Ever See New E/M Guidelines?

Will We Ever See New E/M Guidelines?

UPDATE! Read the article “New Guidance Is Good News for E/M Service Coding” on page 54 of the May issue for new guidance that may help to make exam requirements clearer.

They were problematic 20 years ago and are even more so with today’s technology.

There are two sets of evaluation and management (E/M) services guidelines — one created in 1995 and the other in 1997 — to help coders better understand the documentation requirements for coding these services. Twenty years later, the guidelines are the same despite drastic changes in coding, documentation methods, and the medical industry.

Evaluation and Management – CEMC

New E/M guidelines are needed. Both the 1995 and 1997 guidelines caused confusion when they were released, and much of that confusion remains. A host of concerns has arisen since the inception of electronic health records (EHRs) that make the need for new guidelines more evident.

Where E/M Guidelines Fall Short

Let’s explore some areas where the present E/M guidelines fail.

There are two sets of guidelines: The 1995 guidelines did not go away when the 1997 guidelines were created; both sets of guidelines are still used. The industry standard is to use the set of guidelines that provides the best outcome for the provider. One problem with this is that the 1997 guidelines use the status of three chronic conditions to meet an extended history of present illness (HPI), but make it more difficult to achieve a detailed or comprehensive exam. A provider who is seeing a patient for chronic conditions is at a disadvantage as a result. Some payers will allow using the status of three chronic conditions when otherwise following 1995 guidelines, but don’t count on it.

Exam requirements vary: The exam requirements are completely different for each set of guidelines. A primary care provider using 1995 guidelines may reach a comprehensive exam easily when examining multiple organ systems. Reaching a comprehensive exam using the 1997 guidelines, which usually are used by specialists who may not need to examine as many organ systems, is much more difficult.

1995 exam guidelines are confusing: The 1995 guidelines recognize four types of exams: problem-focused (PF), expanded problem-focused (EPF), detailed, and comprehensive. The definition of EPF and detailed differ only by one word: An EPF exam requires a limited examination of the affected body area or organ system(s); whereas, a detailed exam requires an extended examination of the affected body area or organ system(s). Nowhere in the guidelines is limited or extended defined, which may leave you wondering what is required in the documentation to support these types of exams.

Who can document certain elements is unclear: The guidelines specifically state the review of systems (ROS) and the past, family and social histories (PFSH) can be documented by ancillary staff and reviewed by the physician. Nowhere do they state the ancillary staff can document HPI, exam, and assessment and plan; however, they also do not state the provider must document them. Over the years, it has become standard to assume the provider must document these elements. How great would it be if the guidelines could confirm this plainly and simply?

Determining medical decision-making (MDM) is not easy: The guidelines for both 1995 and 1997 guidelines recognize four types of MDM necessary to support the levels of E/M services. The following chart comes from the guidelines:

The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.

When determining the type of MDM the documentation supports, there must be indication as to whether the patient (developing significant complications, morbidity, and/or mortality) is of minimal, low, moderate, or high risk. A table of risk is included in the guidelines to help in this area; however, the guidelines do not provide further explanation of what is required for the number of diagnoses, management options, or the amount and/or complexity of data reviewed. Over the years, tools have been developed to help coders and auditors make sense of the MDM (e.g., the popular Marshfield Clinic Tool), but not all payers recognize the tools. Here again, we have a clear example of why new guidelines are so necessary.

How EHRs Affect the Debate

EHRs also factor into the need for new guidelines.

The person who documented can be unclear: With the use of EHRs, we see issues that pertain directly to the documentation of E/M services. First, paper records make it very evident when someone other than the physician documented areas inappropriately. If the handwriting for the HPI is different than that for the exam and assessment and plan, for example, you can ask, “Who documented what?” In an EHR, it’s not so obvious. Some systems use a signature stamp to identify the user who documented each area, but this is not standard.

Mass-produced documentation can bump up E/M level: There is the issue of copying, pasting, cloning, template use, etc. EHRs use these features to make documentation easier for providers, but they may cause issues related to the documentation of E/M services and meeting the elements outlined in the guidelines to support the level billed.

Copying and pasting: For example, the documentation typically does not acknowledge if an ROS is copied and pasted from a previous visit, making it appear as if the ROS was documented for that encounter. The guidelines state an ROS can be used from an earlier visit; however, the encounter date from which it came must be referenced, along with the provider documenting that the ROS was reviewed, and whether any changes were made, etc. To copy and paste the information from an earlier visit without reference to where it came from does not meet the guidelines.

EHRs may not clearly indicate in the encounter note that something was copied and pasted from an earlier visit (although “audit trails” allow you to determine who documented what, and from where). Payers are looking at multiple visits for the same patient to determine if the documentation looks the same from one visit to the next. This is a concern that has caught the attention of the Office of Inspector General (OIG) in the past, and was a target on their 2014 Work Plan.

Regarding the exam, the guidelines do not state an exam from an earlier date can be used. Can an exam be copied and pasted from an earlier visit? A payer would most likely say no.

New E/M guidelines that address issues pertaining to the advances in technology since 1997 are vital to documenting in the electronic age.

Templates: Because templates and other features in the EHR have made it easier and faster to document, an increase in comprehensive histories and exams has developed. This has resulted in an increase in billing higher-level E/M services. Payers are taking notice, and wondering if they should be paying for these services. The Centers for Medicare & Medicaid Services (CMS) states:

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.

In other words, just because a comprehensive history and exam are performed does not mean it is appropriate to bill 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. A physician must look at why the patient came in, the nature of the presenting problem, and determine the appropriate level of service.

Let’s Get with the Times

As you can see, there are many areas where the 1995 or 1997 E/M documentation guidelines leave questions. New guidelines that address these issues and catch up with technology are desperately needed. Let’s hope that day comes soon!


CMS: www.cms.gov

OIG 2014 and 2017 Work Plans: https://oig.hhs.gov/reports-and-publications/workplan/

American Medical Association, CPT® 2017

1995 Documentation Guidelines for Evaluation & Management Services:



1997 Documentation Guidelines for Evaluation & Management Services:



Ellen Hinkle, CPC, CRC, CPMA, CPC-I, CEMC, CFPC, CIMC, has over 18 years of medical billing and coding experience. She works for Visionary Health Group/Community Health Network as a coding auditor responsible for auditing medical record documentation to ensure documentation supports the services billed and that HIPAA, compliance standards, and government and network policies are adhered to. Hinkle has also taught AAPC’s PMCC curriculum and has worked as an online adjunct instructor providing instruction and expertise to her students in the areas of medical billing and coding. Hinkle is a member of the Indianapolis, Ind., local chapter.

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