Future E/M Guidelines Could Provide Greater Reimbursement

Just when many infectious disease (ID) physicians had gotten accustomed to performing the more detailed examination requirements of the Health Care Financing Administrations (HCFA) 1997 evaluation and management (E/M) documentation guidelines, the agencys recently issued proposal for new guidelines indicates that a less restrictive examination system is being considered for adoption in January 2002. In the meantime, ID physicians should continue to follow either the 1997 or 1995 guidelines issued by HCFA and make sure that they are properly documenting the examination component of the E/M service.

In an attempt to distinguish between different levels of E/M service, HCFA issued E/M documentation guidelines in both 1995 and 1997with the section on examinations being the main difference between the two. The 1995 guidelines allowed physicians to conduct either a general multisystem or single system exam, and defined the levels of examination in a basic way.

There was no specific guidance, however, on what constituted the difference between the various levels of examination for coding and reimbursement purposes, which caused concern among physicians. In the 1995 guidelines, an expanded problem-focused exam was defined as a limited examination of affected body systems, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J.

Three Tips for Better Exam Documentation

What the ID physician does to document the examination probably will be the same for both the 1997 and the June 2000 guidelines, according to Gottlieb.

What the physician documents will remain the same, he says. The new guidelines look like they will require fewer elements for an examination, and physicians may be able to bill a higher level of service than under the 1997 standards.

The following three tips on documenting examinations will apply to whatever set of standards (1995, 1997 and June 2000) are in effect:

1. Checklists and templates make documentation easier. It takes longer to write everything down than to do the exam, claims Weinstein. Thats why I have a template for exams, where I can quickly check off all of the normal or negative elements.

Brink agrees that a checklist can be helpful. HCFA has said that it is okay to check off when an element is normal, you dont have to write it all down, she explains.

2. Documenting patient history helps justify exam. Brink cautions ID physicians who skimp on the history portion of the E/M service with an established patient and focus solely on the exam portion. A physician only needs to document two out of three components (history, examination and medical decision-making) for an established patient visit, she says. But the information obtained by the physician in the history, history of present illness (HPI) or interval history [...]

- Published on 2000-08-01